A Time Study Analysis of Fluoride Varnish Application in PediatricWell Visits to Address Health Disparities among Children

Background: Dental caries is the most common chronic childhood disease. In early childhood, it is associated with many negative factors such as pain, loss of teeth, and impaired growth. Fluoride varnish (FV) is a protective resin coating treatment that is reimbursable by most insurances and is recommended by the American Academy of Pediatrics (AAP), United States Preventative Services Task Force (USPSTF), and the American Dental Association (ADA) due to its high efficacy in preventing dental caries. FV is a low-cost treatment that can be easily applied in 1-2 minutes during a well-child visit in the primary care setting, where children are seen frequently by primary care providers in the first few years of life. Objectives: To educate pediatric primary care providers on FV treatment and increase their willingness to provide these treatments in clinical practice, therefore setting the foundation for FV implementation in the pediatric primary care setting. Methods: A one-time FV treatment educational session was given to pediatric primary care providers. A pre- and post-survey was provided to the providers to measure knowledge level and willingness to provide FV treatment before and after the educational session. Results: Results concluded that the pediatric primary care providers had and increased knowledge of FV treatments and were more willing to offer these treatments in their clinical practice at the 1-week post-education mark. Conclusions: Future research is needed to further assess the implications and outcomes of FV education and treatment implementation in the pediatric primary care setting.

42. HEALTHY SMILE HAPPY START

Integrating Fluoride Varnish Delivery in Primary Care: Insights from a Workflow and Cost Analysis.

Introduction: Dental caries is the most common chronic disease in children from birth through 5 years of age. Application of fluoride varnish (FV) is recommended for children younger than 6 years every 3 to 6 months by the United States Preventive Services Task Force. The purposes of this study were to (1) assess use and reimbursement of Current Dental Terminology (CDT) D1206 and Current Procedural Terminology (CPT) 99188 codes, which are the billing codes for FV application; (2) determine when and by whom each FV code was used; and (3) summarize the associated clinical notes. Methods: Using the electronic medical record data warehouse from a single tertiary teaching hospital and its affiliated primary care clinics, the dates of service, departments, provider names, and patient identifiers associated with codes CDT D1206 and CPT 99188 were collected. The content of clinical notes was reviewed and summarized. The study period was from May 1, 2009 through May 17, 2019. Results: During the 10-year time period, CDT D1206 was used 5 times and CPT 99188 was used 35 times. FV was applied exclusively during well-child visits. Only pediatricians, and no family physicians, applied FV in this setting. Discussion: A single pediatrician championing for FV application increased both the completion of procedure and the appropriate billing in 2019. Conclusion: FV application has been likely underutilized in this Midwestern tertiary teaching hospital and its affiliated clinics. For both family medicine and pediatric offices, an advocate for caries prevention is likely needed for successful implementation of FV application at well-child visits.

The United States has a public health crisis of dental caries in children's primary teeth. Fifty-five percent of children have dental caries by age 8. The majority of these children are nonwhite and poor. Caries could be decreased by 40% if fluoride varnish (FV) application started with tooth eruption. A four-month FV application QI project was implemented in a rural pediatric practice. The staff was trained by the Vermont Department of Health using the From the First Tooth protocol. Children aged 9, 18, 24, and 30months. Pre- and postproject questionnaires were completed. A caries risk tool assessed a child's risk and access to dental care. Completed FV applications were recorded and staff interviewed weekly. FV application was offered at well child checks (WCCs). Fifty-six percent of sample patients received FV at their WCCs. Qualitative themes included the following: reasons subjects did/did not receive FV, ease of FV application, increased oral hygiene education, visit flow, application time, older children's FV need, and billing issues. This economical, FV application program can be readily implemented by nurse practitioners and nurses in pediatric practices where children have inadequate dental care.

Topical fluoride varnish application shifts dysbiotic dental plaque microbiome towards eubiosis in children with dental caries

Dental caries are preventable yet remain one of the most common chronic diseases [1]. Untreated dental disease negatively impacts quality of life and results in pain, leading to school absence and malnourishment [2]. The American Dental Association advocates the first dental visit by age one, followed by biannual visits [2]. Unfortunately, data reveals 3.6% of 1-year-old infants have an established dental home [3], highlighting a paucity in crucial oral health guidance. Topical fluoride application, particularly fluoride varnish, is shown to be effective in caries prevention; clinical trials have reported a 70% caries risk reduction [4]. State Medicaid programs have reimbursed in-office fluoride varnish applications since 2017 [5], yet states vary in utility of this intervention. Sixteen states report < 2% of eligible Medicaid-enrollees received fluoride varnish in a non-dental setting, whereas only three states reported ≥ 20% of eligible Medicaid-enrollees receiving fluoride varnish [5]. Primary care providers (PCPs) see 88.8% of infants and 1-year-olds annually [3] and can effectively bridge this gap. Equipping PCPs with fluoride varnish application skills, knowledge of diet, and oral hygiene counseling empowers oral health promotion. Grant funding by nccPA Health Foundation and Arizona Delta Dental supported the unique, interprofessional opportunity, with physician assistant (PA) faculty, dental faculty, and students, to address this gap through hands-on oral health training of PA students. This innovative program included an interactive 90-min didactic session highlighting: the impact of oral health on systemic health, caries disease progression, and the preventative benefits of topical fluoride. Dental students and faculty taught fluoride varnish application skills, while also highlighting the importance of nutrition and culture with a focus on oral health from an equity lens. Students were given university cafe credits to gain awareness of the potential challenges of purchasing anticariogenic foods, with attention to cultural sensitivity, cost, and access. Students engaged in community outreach, assembling hundreds of oral health products, including patient education resources. Items were utilized for service-learning activities while caring for patients experiencing homelessness. The workshop effectively emphasized the importance of PCPs prioritizing preventative health, healthy eating, and health equity. PA students were invited to complete a survey focused on the relevance of this activity to primary care PA practice. The response rate was 84% (79/94) and demonstrated 100% of survey participants strongly agreed or agreed that the training taught skills relevant for a primary care PA (Table 1). In addition to skill training, this workshop demonstrated the critical implications of oral health within primary care practice, the benefits of interprofessional collaboration, and the value of gaining hands-on, practical knowledge through an interactive interdisciplinary experience. PAs and other PCPs play an integral role in oral health promotion. What went well included the students’ receptivity to learning with and from one another, the appreciation of collaboration, along with the increased awareness of nutrition and anticariogenic properties of food. One area for improvement would be to avoid scheduling fluoride varnish application immediately prior to the lunch hour. Lessons learned include the students’ appreciation of hands-on, relevant, and engaging activities. Early exposure to interprofessional teamwork facilitates greater awareness of the importance of working together to support equity and community health. The authors thank nccPA Health Foundation and Arizona Delta Dental for providing funding for this project. The authors declare no conflicts of interest.

ImportanceDental caries is the most common chronic disease in children in the US. According to the 2011-2016 National Health and Nutrition Examination Survey, approximately 23% of children aged 2 to 5 years had dental caries in their primary teeth. Prevalence is higher in Mexican American children (33%) and non-Hispanic Black children (28%) than in non-Hispanic White children (18%). Dental caries in early childhood is associated with pain, loss of teeth, impaired growth, decreased weight gain, negative effects on quality of life, poor school performance, and future dental caries.ObjectiveTo update its 2014 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review on screening and interventions to prevent dental caries in children younger than 5 years.PopulationAsymptomatic children younger than 5 years.Evidence AssessmentThe USPSTF concludes with moderate certainty that there is a moderate net benefit of preventing future dental caries with oral fluoride supplementation at recommended doses in children 6 months or older whose water supply is deficient in fluoride. The USPSTF concludes with moderate certainty that there is a moderate net benefit of preventing future dental caries with fluoride varnish application in all children younger than 5 years. The USPSTF concludes that the evidence is insufficient on performing routine oral screening examinations for dental caries by primary care clinicians in children younger than 5 years and that the balance of benefits and harms of screening cannot be determined.RecommendationThe USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. (B recommendation) The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening examinations for dental caries performed by primary care clinicians in children younger than 5 years. (I statement)

Fluoride varnish application is an effective intervention in controlling dental caries. Objective of this study was to evaluate the effectiveness of six monthly application of sodium fluoride varnish in prevention of dental caries in deciduous teeth, permanent incisors and molars in children between six and seven years in a low resource setting, Sri Lanka. This was an open-label, randomized controlled trial (NCT02877888) in school children aged six to seven years, living in a district of Sri Lanka. Recruited children were randomly assigned to either a treatment (n=161) or to control group (n=162). Children in the treatment group received fluoride varnish professionally applied every 6 months combined with counselling on maintenance of oral hygiene and diet for a period of 2 years. Caries examinations were conducted using the International Caries Detection and Assessment System (ICDAS). The primary outcome studied was the number of new caries in the two study groups. At each time interval, the mean number of new dental caries was significantly lower in the intervention group. When independent effect of the intervention on development of new dental caries was assessed, application of fluoride varnish every 6 months for a period of 2 years was significantly associated with less number of new dental caries compared to controls. Fluoride varnish application in a low resource setting is an effective method of preventing dental caries among children. A national level programme would contribute to the reduction of dental caries in this age group. Keywords: Clinical trial, Fluoride varnish, Dental caries, Caries prevention, Effectiveness

<h3>Context:</h3> Dental decay is the most common chronic disease in children, with racial minorities and children living in poverty having the highest prevalence. Dental fluoride varnish, a protective coating painted on teeth to help prevent caries, requires no special equipment and can be applied in &lt;2 minutes. Per the USPSTF and American Academy of Pediatrics, dental varnish application should be considered every 3-6 months during well child exams. <h3>Objective:</h3> Evaluate incorporation of fluoride varnish applications in well child visits. <h3>Study Design:</h3> Mixed-methods. <h3>Setting:</h3> Two residency clinics in Milwaukee, WI. <h3>Population studied:</h3> 6 month - 6 year well child visits, pre/post-provider survey. <h3>Intervention:</h3> Dental varnish application protocol was implemented in July–Sept. 2019. All providers completed the STFM Smiles for Life Module 6. <h3>Outcome measures:</h3> Pre/post-surveys were conducted to identify provider’s opinions including importance, sustainability, and barriers to implementation of a dental varnish protocol. Well child visit data from 7/1/19 1/15/20 (period 1) and 1/16/20 - 12/31/20 (period 2; representing COVID pandemic) was compared for both clinics regarding rates of preventative visits with fluoride dental varnish applied. A Z-test for Equality of Two Proportions was used to compare rates. Pre/post-survey answers were analyzed using 2-sample T–tests. <h3>Results:</h3> 1,984 well child visits in study period; 369 (19%) with varnish application. During period 1, 25% of visits at clinic 1 and 16% of visits at clinic 2 included a varnish application. There was no significant difference in application rates between periods (clinic 1=22% visits and clinic 2=15%). During the Covid-19 pandemic varnish applications decreased from 18.6 to 8.1 per month at clinic 1 (p&lt;0.01), but increased from 12.5 to 15.2 per month at clinic 2 (p=0.18). Our pre/post-surveys identified the same barriers to application (not enough training/time, unsure where to find supplies). Except for percentage of eligible patients seen for well child exams including fluoride varnish (63% v. 35% p&lt;0.01), no other survey responses were significantly different. <h3>Conclusions:</h3> Dental fluoride varnish application can be successfully implemented into academic primary care clinics to reach children most at risk, but not without challenges. Results of further surveys can be used to streamline protocols for sustainability. Optimized processes may be adapted by others to decrease health disparities.

Dental decay is most prevalent among low socio-economic status (SES) groups where cost limits access to dental care. To address inequities in oral health outcomes, Alberta Health Services (AHS) Oral Health Action Plan encompasses a population health approach that redirects fluoride varnish (FV) applications to low SES children. Using low SES measures to establish the eligibility criteria is fundamental to the delivery of FV applications to the target population. A series of four FV applications over two years is directed to children age 12-35 months and two applications per year to children in Kindergarten and grades 1 and 2, using low SES measures for eligibility criteria. The provincial objective for children receiving the first FV application is 10%-20% of the population age. Additional objectives are set for rates of subsequent FV applications for each population group. From 2015 to 2016, the rate of first FV applications for eligible target populations is below the provincial objective for children age 12-35 months (5%) and within the objective for children in Kindergarten and grades 1 and 2 (16%). Rates of subsequent FV applications in the school setting are being met. Encompassing a population health approach to deliver standardized fluoride varnish applications to low SES children better targets inequities in oral health outcomes in Alberta. Challenges of redirecting the FV intervention include creating the eligibility criteria and engaging the target population, particularly for the preschool population. Achieving population objectives are challenged by unequal distribution of resources across the province.

To identify the relationship between the preventive and restorative care provided to children who frequently attend the General Dental Service in the UK after taking into account socio-economic status, gender and dental caries experience. General dental practices in the North West of England. The study design involved a retrospective investigation of case notes of 677 children who regularly attended 50 general dental practitioners. The complete history of the dental care received by each child during the primary dentition period was recorded. Analyses took place at the patient level. Information was recorded on the total number of carious teeth and restorative and preventive care provided to the children. Preventive care was categorised as dietary advice, oral hygiene instruction, prescription of fluoride tablets and application of fluoride varnish. Socio-economic status was measured using the Townsend score of the electoral ward of residence of each subject. Logistic regression models, taking into account the clustering of the subjects within dental practices were fitted to identify whether or not socio-economic status was significantly associated with provision of each category of preventive care, after controlling for gender, the total number of teeth affected by caries and the proportion of carious teeth which were restored. Children from poorer backgrounds were significantly more likely to receive oral hygiene instruction than their more affluent peers. Socio-economic status did not influence dentists' decisions to prescribe fluoride tablets, but children from affluent backgrounds were significantly more likely to have fluoride varnish applied to their teeth than children from deprived backgrounds after controlling for other factors. The more teeth affected by decay significantly increased the odds of giving dietary advice, prescription of fluoride tablets and application of fluoride varnish, but had no effect on whether or not oral hygiene instruction was given. As the percentage of decayed but filled teeth decreased the odds of giving dietary advice or applying fluoride varnish increased significantly. Conclusion It would appear that dentists are providing appropriate preventive care according to the aetiological causes of dental disease. They also look to be providing preventive care in compensation for decisions not to restore carious primary teeth. However the preventive care provided seems to be reactive to disease patterns, and in this high risk group of patients does not seem to be particularly effective.

This study investigated the relative effectiveness of school-based versus clinic-based fluoride varnish (FV) application within a single program in Taiwan. Data for the phase 1 study (population-based analysis) were extracted from Taiwan's National Health Insurance Research Database (NHIRB). The phase 1 cohort included 347,544 children born in 2015 or 2016 who received FV application services at school, in a dental clinic, or in both settings. FV services were recorded using specific codes: 88 and 89 for school-based FV application and 81 and 87 for clinic-based FV application. During follow-up, primary molars were assessed for caries-related treatments. The phase 2 (fieldwork) cohort included 1,479 children examined for early childhood caries (ECC). Their data were linked to the NHIRB to obtain corresponding data on the FV application. In both phases, logistic regression was performed to determine the associations of application setting with the odds of caries-related treatments and ECC. The odds of the following treatments were significantly higher with school-based FV application than with clinic-based FV application (all Ps < 0.0001): dental restoration (odds ratio [OR] = 1.09; 95% confidence interval [CI], 1.06-1.11), endodontic treatment (OR = 1.21; 95% CI, 1.16-1.26), and tooth extraction (OR = 1.33; 95% CI, 1.25-1.42). This difference was particularly prominent in moderately and highly urbanized areas. Furthermore, the risk of ECC was higher with school-based FV application (OR = 1.52; 95% CI, 1.10-2.11; P < 0.05) than with school-based FV application. However, after covariate adjustment, both groups had similar risk estimates (OR = 1.03; 95% CI, 0.71-1.50). Clinic-based FV application significantly reduces the likelihood of caries-related treatments for primary molars. Future studies should consider our findings when evaluating the effectiveness of FV application.Knowledge Transfer Statement:Compared with school-based FV application, clinic-based FV application significantly reduced the likelihood of caries-related treatments, particularly among children residing in urban areas. For children who received only school-based FV application services, dentists may recommend additional clinic-based FV application services. Our findings may guide future studies aimed at evaluating the effectiveness of FV application.

Caries incidence during a 2-year period was studied in 4- to 5-year-old children from three areas with contrasting levels of natural fluoride (F) in the drinking water and different regimens of topical fluoride varnish applications; group A (n = 448) was from an area with a low level of F (0.1 ppm) and semi-annual applications of fluoride varnish; group B (n = 374) was from a low F area (0.1 ppm) and no fluoride varnish treatments; group C (n = 206) was from an area with optimal F (1.2 ppm) and fluoride varnish treatments. All children were clinically assessed at baseline and after 2 years according to WHO criteria. The number of salivary mutans streptococci was estimated and scored at baseline and after 2 years with the Strip mutans method. The varnish containing 0.1% F was applied every 6 months on all accessible tooth surfaces after cleaning with a pumice paste. Basic preventive care was given to all children and restorative treatment on individual indications. Higher levels (p < 0.05) of salivary mutans streptococci were found in the low-fluoride areas compared to the optimal fluoride area at baseline and after 2 years. The caries incidence (mean dft +/- SD) in the different groups was A: 0.65 +/- 1.40; B: 1.09 +/- 1.85; C: 0.53 +/- 1.09. The difference between group B and groups A and C was statistically significant (p < 0.05). A positive relationship (p < 0.05-0.001) between salivary mutans streptococci scores at baseline and caries incidence was found in all three groups. This study confirms the close association between salivary mutans streptococci and caries incidence in preschool children and suggests a caries-reducing effect of topical applications of the fluoride silane varnish.

INTRODUCTION Prevention of dental diseases in children requires interprofessional education (IPE) and care coordination between oral health professionals and primary care providers; however, the extent of preparation of medical residents and its impact on their provision of preventive oral health services in clinical practice requires further investigation. METHODS A two-stage cluster sample of 470 US family medicine and 205 pediatric residency programs was used. A random sample of 30% (N=140) of family medicine and 29% (N=60) of pediatric residency programs were randomly selected. Of these, 42 programs (21%) invited residents to participate. Residents (N=95, 28%) completed an online questionnaire regarding oral health training in residency. Statistical analysis included frequencies and Spearman’s rank correlations. RESULTS Eighty-three percent of family medicine and pediatric residents combined reported receiving oral health education. Clinical experiences involving oral healthcare were frequently reported (77%, n=75); however, IPE with an oral health professional was limited. Both groups indicated they provided anticipatory guidance regarding regular dental visits and toothbrushing “very often” and avoiding bottles at bedtime “often.” Residents reported performing dental caries assessments “often” and applying fluoride varnish “occasionally.” For family medicine residents, moderate correlations (p ≤ 0.01) were found between hours of oral health education and providing anticipatory guidance. For pediatric residents, a moderate correlation (p < 0.01) was found between hours of oral health education and assessing teeth for demineralization. CONCLUSION Increased effort is needed to meet national recommendations for educating family medicine and pediatric residents regarding oral healthcare for children, including increased IPE involving oral health professionals. Received: 05/25/2015 Accepted: 08/28/2015 Published: 10/22/2015 © 2015 Bailey et al. This open access article is distributed under a Creative Commons Attribution License, which allows unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. H IP & Oral Health and Interprofessional Education ORIGINAL RESEARCH 2(3):eP1081 | 2 Introduction Oral health is a vital component of overall health and, therefore, the responsibility of pediatricians. Accordingly, the American Academy of Pediatrics (AAP) recommends pediatricians play an integral role in children’s oral health by providing preventive oral health services including anticipatory guidance, oral health screenings and assessments, and fluoride varnish applications during well-child visits (AAP, 2014). This recommendation applies not only to pediatricians but to other primary care providers (PCP), such as family physicians, nurse practitioners, and physician assistants (PA) (National Interprofessional Initiative on Oral health [NIIOH], 2011). In 2014, the U.S. Preventive Services Task Force (USPSTF) recommended PCP prescribe fluoride supplementation to children beginning at 6 months of age if they reside in areas with suboptimal fluoride concentration in the drinking water and provide fluoride varnish applications to all children beginning at eruption of the first tooth (USPSTF, 2014). In support of these recommendations, medical insurers are requir-ed to reimburse providers under the Affordable Care Act (ACA) for services assigned a grade A or B by the USPSTF. This reimbursement includes fluoride varnish applications for children ages 0-5 years (Kaiser Family Foundation [KFF], 2014). These national children’s oral health initiatives coincide with the recent emphasis on integrating interprofessional education (IPE) opportunities across the healthcare professions to improve the health of the nation and overall quality of care (Institute of Medicine [IOM], 2011). IPE opportunities involving oral health experts such as dental hygienists, dentists, and/or dental professional students are integral to effectively train PCP to de-liver preventive oral health services to children. Little is known about IPE opportunities involving dental professionals in family medicine and pediatric residencies. Patients of all ages experience needless dental diseaserelated pain and expense, in part, because their PCP has not been trained to provide preventive oral health services (NIIOH, 2009). The general health status of children and adolescents can be improved by prevention and early intervention of oral diseases, including dental caries, before they develop into more complicated Implications for Interprofessional Practice