Section 5: Fluoride Varnish Application (FVA)
Upon completion of this section, participants will be able to:
- Discuss the C&TC requirement for FVA
- Discuss why FVA is important in the C&TC setting
- Identify FVA considerations for the primary care setting
- Identify resources for:
- C&TC FVA recommended online trainings
- C&TC billing questions
Fluoride Varnish Application Recommendations
Fluoride varnish application (FVA) is now required at every C&TC visit for infants beginning at the eruption of the first tooth through age 5. Fluoride varnish may also be applied on the teeth of older children based on risk factors.
The United States Preventive Services Task Force (USPSTF) issued a recommendation in 2014 that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (Clark, Slayton, and the Section on Oral Health, 2014).
The Centers for Medicare and Medicaid Services (CMS) recommends "making fluoride varnish application a standard component of well-child visits for children younger than 6 years of age" (Centers for Medicare & Medicaid Services, 2015).
About Fluoride Varnish
Fluoride varnish is a topical application that is applied with a small brush. Applying fluoride varnish is a quick and easy procedure. It takes less than five minutes to apply. Typically, fluoride varnish comes in a 5% sodium fluoride preparation. Single dose units are recommended as they can be opened and applied to the brush quickly without risk of spilling or over application. In general, the single dose units come in two sizes; 0.25 ml can cover the primary teeth and most permanent teeth and can be used until the child has all their adult teeth. The 0.4 ml single unit dose can be used to cover a full set of adult teeth.
Why is Fluoride Varnish Important?
Fluoride varnish prevents dental caries from forming. It can reverse early dental caries that are just beginning to form. It can stop dental decay that is already present from worsening. The effect of fluoride varnish has protective effects that last several months (Dalal, 2017).
How does it work?
Fluoride varnish binds with the surface tooth enamel on contact with saliva. This makes the tooth more resistant to decay. Fluoride prevents mineral loss in tooth enamel. It also decreases the ability of bacteria to produce acid that can damage tooth enamel.
How safe is it?
Fluoride varnish is safe to use on teeth beginning with the eruption of the first tooth which can occur very early in infancy. Because it hardens on the teeth on contact with saliva, it is not easily swallowed.
Studies on fluoride blood levels and urine excretion after application of fluoride varnish have found levels within the safety limits established by the Environmental Protection Agency and the National Academy of Sciences (Milgrom, Taves, Kim, Watson, Horst, 2014).
For a demonstration on how simple and quick it is to apply fluoride varnish on a small child, view this short video on fluoride varnish application and see images 1-6 below.
|Image 1: Fluoride Varnish Application (FVA) is being applied on the child's teeth|
|Image 2: Dentist is juggling balls while playing a harmonica as a young child looks on attentively|
|Image 3: Child being prepared to lie down in knee to knee on mom and dentist's laps|
|Image 4: Mom and dentist are knee to knee supporting child's body|
|Image 5: Child laying in knee to knee position receiving FVA|
|Image 6: Post fluoride varnish application, child appears calm and happy|
Images 1-6 Under 3 year old child receiving fluoride varnish treatment. With permission from Lodi Dental
You may also want to watch this video by the Minnesota Oral Health Coalition and Minnesota Chapter of the American Academy of Pediatrics on Applying Fluoride Varnish by Staff in a Clinic Setting.
Who can apply it?
Fluoride varnish may be applied by a physician or other qualified health care professional such as a nurse practitioner or physician assistant. It may also be applied by trained clinic staff under the supervision of a qualified health care professional.
Medical assistants and other non-licensed personnel performing fluoride varnish as a delegated task must review either Smiles for Life: Module 6 Caries Risk Assessment, Fluoride Varnish and Counseling slides 35 to 39, or MN Oral Health Coalition's video on fluoride varnish application
Providers and those who supervise staff applying fluoride varnish should watch the complete Smiles for Life: Module 6 Caries Risk Assessment, Fluoride Varnish and Counseling training.
Obtaining FVA consent
The Minnesota Health Care Provider (MHCP) manual requires informed consent be obtained from a parent or guardian prior to FVA. The MHCP manual states:
- Written consent is valid for one year.
- Verbal consent should be obtained each time FV is applied (up to 4 times per year).
- Documentation of obtained consent, either verbally or in writing, should include application of fluoride varnish and who applied it, benefits and risks explained, and anticipatory guidance
FVA is a covered service for children from birth to age 21 years who are eligible for Medical Assistance. The Current Procedural Terminology (CPT) code 99188 can be used in a clinical setting to bill for FVA provided by primary care providers (physicians, physician assistants or nurse practitioners) and trained licensed or certified clinical staff. Clinics may bill as often as every three months; up to 4 times a year.
More information regarding FVA billing can be obtained by referring to the Fluoride Varnish Application section of the Minnesota Health Care Provider Manual.
Frequently Asked Questions About Fluoride Varnish (FAQ)
How does it compare with other fluoride varnish treatments?
FVA provides a higher level of protection than tooth paste or fluoride in the water. It is equal to other professionally applied dental fluoride treatments. It is less expensive and without the risks of systemic exposure to fluoride. It also stays on the teeth longer than other treatments and offers sustained protection against caries.
What is the evidence?
High quality evidence supports the efficacy of fluoride varnish in preventing and controlling dental caries. It has also been recommended by the American Academy of Pediatrics, The American Academy of Pediatric Dentists, the Centers for Disease Control, and the United States Preventive Services Task Force.
Is there a fluoride varnish handout that providers can give families?
The AAP Children's Oral Health website has an after fluoride varnish handout for families in English and eight other languages.
Is there a fluoride varnish that tastes good?
There are a lot of brands out there with different flavors. Remember you want the pediatric size which is typically 0.25 ml for the individual doses. Not all fluoride varnish with flavors are offered in pediatric doses. Bubblegum and cherry are the preferred flavors for children; avoid the watermelon and mint.
1. All of the following is true about fluoride varnish application (FVA) except:
2. C&TC FVA requirements and recommendations include the following: