Fluoride varnish in the Child and Teen Checkups Setting

U.S. Preventive Services Task Force (USPSTF) 2021 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." This Grade B recommendation indicates strong evidence that the "net benefit is moderate to substantial".

Dental caries is the most common childhood chronic disease in the United States. Even though dental caries is preventable, it continues to be a significant problem for many children in Minnesota. In the last 20 years, the prevalence of dental caries in children has been increasing, particularly in young children ages 2 to 5 years. Children from low-income families and those without access to care or dental insurance are at high risk for dental caries. This has negative health, educational, and financial effects on the child, family, and society.

Poor dental health in low-income children can be attributed to a lack of access to proven preventive measures, including sealants and fluoridation, too few dentists available to treat Medicaid-enrolled children; and in some communities, not enough dentists to provide care. While efforts are in progress to improve access to dental care for young children in Minnesota, the current reality is that many children do not see a dentist until cavities have already formed.

Primary healthcare providers are in a unique position to help prevent dental caries. Most Medicaid-eligible children in Minnesota receive at least one of their recommended C&TC visits every year. Fluoride varnish application in the context of a clinic visit is an easy, safe, and effective way for primary care providers to prevent dental caries. Studies show that fluoride varnish, along with family education, reduces early childhood caries.

Fluoride varnish:

• Is a topical treatment applied on the surfaces of teeth using a small brush and sets on contact with saliva.
• Prevents new cavities from forming and helps stop tooth decay that has already started.
• Has a protective effect that lasts several months.

In the C&TC setting, fluoride varnish should be applied to the teeth of all infants and children at minimum at C&TC visits up to four times a year, starting when the first tooth erupts. This is in addition to fluoride varnish that is applied in a dental home.

Fluoride varnish is safe to use on babies' and young children's teeth. Fluoride varnish significantly minimizes the risk of ingestion that exists with traditional fluoride treatments because only a small amount of varnish is used, and the varnish adheres to teeth immediately, reducing the risk of swallowing.

Fluoride varnish application is a quick and easy procedure.

Fluoride varnish must be applied by a physician or other qualified health care professional, a clinic staff member who works under the supervision of a qualified health care professional, or other allied health providers who have completed one of the recommended online FVA trainings. Staff training staff is not recommended.

Fluoride varnish should not be given to families to apply at home.

1. Anyone applying fluoride varnish must complete a C&TC recommended training.
2. Obtain verbal or written consent from a parent or legal guardian before applying fluoride varnish. If it is verbal consent, it must be obtained each time before applying fluoride varnish. The verbal consent must be documented in the child's chart and it should include that a discussion of the risks and benefits of FVA took place. The signed consent form must be kept on file with the child's health records. Consent forms are valid for one year.
3. Refer to Fluoride Varnish Application in the MHCP Provider Manual, C&TC Section.

Recommended online trainings:

• Medical assistants and other non-licensed personnel performing fluoride varnish as a delegated task must review MN Oral Health Coalition's video on fluoride varnish application
• Providers and those who supervise staff applying fluoride varnish should watch the Smiles for Life: Caries Risk Assessment, Fluoride Varnish Application 30 minute YouTube video training.

Alternative trainings:

• Smiles for life complete curriculum is a broader overview; the entire course can be completed for continuing medical education.
• Crush Cavities Fluoride Varnish Application Training for Clinics course provides a broad overview of oral health and fluoride varnish.

Note: Although not demonstrated in these videos, appropriate personal protection equipment including eye shields must be worn during fluoride varnish application.

Fluoride varnish application (FVA) is a covered service for children from birth to 21 years who are enrolled in Minnesota Health Care Programs (MHCP). Refer to the Fluoride section of the MCHP provider Manual for the most updated coding and billing information.

For questions about billing, please contact the Minnesota Department of Human Services, Provider Call Center, (651) 431-2700 or (800) 366-5411, or the health plan.

If the recipient is part of the managed care or private insurance plan, contact the health plan directly for their specific billing information.

The AAP Children's Oral Health website has practical information about implementing oral health care in your clinic. Learn how to perform an oral health risk assessment, apply fluoride varnish, and find tools for nutrition and oral health family education. Includes:

• How Should I Set Up My Practice to Include Oral Health?
• What Do I Need to Apply Fluoride Varnish in My Office?
• How and When Do I Provide an Oral Exam and Risk Assessment?
• How Much Fluoride Do My Patients Need?
• How Do I Help Children to Find a Dental Home?
• How Can I Educate Families?
• How Do I Get Paid?

Helpful, free resources are available online for family education. Below are links to materials for use in the clinic setting. Resources include activities for children and videos for staff and families.

Minnesota Resources

Fluoride Varnish Treatments and Your Child Flyer (PDF)

Fluoride Varnish Treatments and Your Child Flyer (Word)

Additional languages available on C&TC Translated Documents web page

Healthy Teeth, Healthy Baby

National Resources

Brush, Book, Bed: How to Structure Your Child's Nighttime Routine

National Maternal & Child Oral Health Resource Center (OHRC)

Cavity Free at Three

Think Teeth

Sesame Street Healthy Teeth, Healthy Me

A verbal referral to a dentist is required at every C&TC visit, beginning at the eruption of the first primary tooth and no later than 12 months of age. Ideally, this initial visit is the start of a dental home.

A dental home is an ongoing relationship between the dentist and the patient, delivering oral health care in a comprehensive, accessible, coordinated, and family-centered way. Because of the specialized training and expertise, the dentist provides an ideal dental home. Lack of access to dental care can be a barrier to establishing of a dental home in some communities. Developing relationships between primary care providers and dentists in the community is essential for increasing access to dental care for all children and improving their oral and overall health.

The American Academy of Pediatrics (AAP) recommends that a child with dental disease have an active referral to a pediatric dentist for diagnosis and treatment.

For help in finding a dentist:

• Get to know the dental providers in your community.
• Contact the health plan listed on the child's insurance card.
• Contact local public health for information about mobile dental clinics and other community dental resources.

• Bright Futures in Practice: Oral Health
• Centers for Disease Control and Prevention, Children's Oral Health
• Children's Dental Health Project
• C&TC FACT Sheet: Oral Health and Fluoride Varnish