Fluoride varnish in the Child and Teen Checkups (C&TC) setting
AAP infection control recommendations:
When suspicion for SARS-CoV-2 is low, standard PPE (face shield, surgical mask and gloves) is recommended, refer to How pediatricians can optimize oral health during pandemic
When performing procedures that could produce expelled droplets of respiratory or oral secretions, tears, or a gag or cough (such as immunizations, injections, oral examinations, or fluoride varnish applications), health care personnel may consider increasing their level of PPE refer to Guidance on the Use of Personal Protective Equipment (PPE) for Pediatric Care in Ambulatory Care Settings During the SARS-CoV-2 Pandemic
Child and Teen Checkups (C&TC) requirements
Fluoride varnish application is now required at all C&TC visits, starting at the eruption of the first tooth or no later than 12 months of age, and continuing through 5 years of age. This can be done as often as 4 times per year in the clinic setting.
In addition to the requirement for fluoride varnish application, the following are oral health requirements for a complete C&TC visit:
- Include the mouth and teeth as a part of the comprehensive physical exam.
- Include oral health and caries prevention in anticipatory guidance.
- Refer every C&TC-eligible child at every C&TC visit for routine dental care, beginning at the eruption of the first tooth and no later than 12 months of age.
(There is a separate C&TC Dental Periodicity Schedule for dental providers.)
In 2014, the U.S. Preventive Services Task Force (USPSTF) published the recommendation 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 is a Grade B recommendation, indicating that there is 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 a preventable condition, 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 (USPSTF). 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 for 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 simply 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. The vast majority of 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.
Implementing fluoride varnish application (FVA) in the C&TC setting
- 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 4 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 risk of swallowing.
Application of fluoride varnish 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.
- Anyone applying fluoride varnish must complete a C&TC recommended training.
- Obtain verbal or written consent from a parent or legal guardian before applying fluoride varnish. If it is a 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 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.
- Refer to Fluoride section of the MHCP Provider Manual, C&TC Section for billing information. Refer to billing 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.
Note: this training was filmed before the COVID 19 pandemic. Please follow the AAP infection control recommendations.
- Smiles for life complete curriculum is a broader overview; the entire course can be completed for free 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 of age 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 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.
A verbal referral to a dentist is a requirement of 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 the 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 establishment 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.
- Healthy Teeth, Healthy Baby - MDH led initiative
- Bright Futures in Practice: Oral Health
- Centers for Disease Control and Prevention, Children's Oral Health
- Children's Dental Health Project
- MDH/DHS, Child and Teen Checkups (C&TC) FACT Sheet for Primary Care Providers: Oral Health and Fluoride Varnish
American Academy of Pediatrics (AAP) Section on Dentistry and Oral Health (2008). Preventive oral health intervention for pediatricians. Pediatrics, 122(6), 1387-1394.
Clark, M & Slayton, R. (2014). Fluoride use in caries prevention in the primary care setting. Pediatrics, 134(3), 626-633.
US Preventive Services Task Force (2014). Prevention of dental caries in children from birth through age 5 years.
Douglass AB, Clark MB, Maier R, et al. Smiles for Life: A National Oral Health Curriculum. 3rd ed. Leawood, KS: Society of Teachers of Family Medicine; 2010. Retrieved May 2014