AAP: Fluoride varnish is billable and implementable

WASHINGTON – With fluoride varnish treatments now on the Bright Futures periodicity schedule, reimbursement is attainable, and pediatricians can focus on integrating the 45- to 60-second procedure into their practices and strengthening their oral health messaging to families.

Pediatrician Melinda Clark and pediatric dentist Rocio B. Quiñonez teamed up at the annual meeting of the American Academy of Pediatrics to deliver this message and to show pediatricians through a hands-on workshop how simple and important fluoride varnishing and oral health counseling are to pediatric preventive care.

^{Christine Kilgore}

Dr. Rocio B. Quiñonez (left) and Dr. Melinda Clark at the American Academy of Pediatrics annual meeting

“We have to own a part of this,” said Dr. Clark of the Albany (N.Y.) Medical Center Pediatric Group. With the dental community overloaded and dental caries the most common chronic childhood disease, “we cannot just cut out the teeth from our medical prevention paradigm.”

Dental caries is five times more common than asthma and seven times more common than hay fever. One in four children begin kindergarten with a history of early childhood caries, and children with the disease are three times as likely to miss school. The disease can progress to local infections, systemic infection, and in rare cases, death.

In 2014, the U.S. Preventive Services Task Force (USPSTF) recommended that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. The USPSTF did not specifically recommend the frequency of application, but in a clinical report published later in 2014 on “Fluoride Use in Caries Prevention in the Primary Care Setting,” the American Academy of Pediatrics recommended fluoride varnish at least once every 6 months – and preferably every 3 months – starting at tooth emergence (Pediatrics. 2014 Sep;134[3]:626-33).

^{Courtesy Dr. Rocio Quinonez}

This child has healthy teeth.

And in September 2015, fluoride varnish was added to the Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents and integrated into the Bright Futures–AAP periodicity schedule.

Both the B recommendation given by the USPSTF to fluoride varnish application and inclusion in the Bright Futures periodicity schedule mean that it is required by the Affordable Care Act to be covered by insurers without out of pocket costs to the patient. Currently, 49 states are reimbursing physicians for fluoride varnish in the Medicaid population.

“It’s become the standard of care,” said Dr. Quiñonez of the division of pediatric dentistry at the University of North Carolina at Chapel Hill.

Fluoride varnish is a concentrated topical fluoride that sets on contact with saliva and helps prevent caries by enhancing remineralization and inhibiting bacterial enzymes. It has been shown to reduce decay by 30%-63%, depending on whether it is coupled with dental health counseling. The treatment has its greatest effect when applied before the onset of caries, but it also may help halt or reverse early carious lesions, which present as decalcified “white spot lesions” along the gum line.

^{Courtesy Dr. Rocio Quinonez}

This child has mild caries.

“We have months, often times many months, to prevent disease and to intervene in the earliest stages [of childhood caries] … before children end up in the hospital or operating room,” said Dr. Clark, a former member of the AAP’s Section on Oral Health Executive Committee and a lead author of the AAP’s report on fluoride use.

She advised taking a systematic approach to applying the varnish. “I often apply it by arches [upper and lower, one dab per arch], as opposed to quadrants,” she said. “As long as you’re painting all the surfaces of every tooth with a thin layer of fluoride varnish, it’s an incredibly safe and effective procedure.”

“And you’ll get good at keeping the tongue out of the way using the gauze,” she said.

Varnish is best applied in infants and toddlers in a knee-to-knee format [provider-to-parent] with the child facing the parent and holding the parent’s hands, and the provider tipping the child into his or her lap. The teeth are dried first with a 2-inch gauze square. The fluoride is painted on with a brush provided with the varnish. Dr. Clark uses a head lamp as a light source so she has full use of both hands. Some providers use a dental mirror to increase visibility, but “I don’t find this necessary for most young children,” she said.

^{Courtesy Dr. Rocio Quinonez}

Varnish is best applied in infants and toddlers in a knee to knee format [provider to parent] with the child facing the parent and holding the parent’s hands, and the provider tipping the child into his or her lap.