Bright Smiles for BabiesFluoride Varnish Program

Virginia Oral Health Partnership for Children

Tiffany C Wright, RDH

Fluoride Varnish Coordinator

Office of Family Health Services

Virginia Department of Health

804-864-7824

tiffany.wright@vdh.virginia.gov

Provider Benefits

• Prevent and reduce risk of tooth decay in children under aged 3

• Develop new skills in:

– Oral screening

– Fluoride varnish application

– Educating parents of young children

– Making dental referrals

• Provide a billable Medicaid service for eligible children

This program was made possible by funding from the Department of Health and Human Services Maternal and Child Health Bureau.

Bright Smiles for Babies

This program does not have a financial association with any company that markets fluoride products

Course Outline• Background

• Early Childhood Caries

• Causative Factors of Tooth Decay

• Fluoride Varnish

• Main Components of Program

– Risk assessment

– Fluoride varnish application

– Anticipatory guidance

– Dental referrals

• Resources

Background

• Oral health status of very young children is declining, especially for low-income and minority populations

• All 50 states reimburse medical providers for preventive dental procedure

• Non-dental providers are ideal partners

Oral Health Care Partnership

• The pediatrician sees the average child 8 – 12 times before aged 3

• 19% of 3- to 4-year-olds have missed well-child visits

• 75% of 3– to 4-year-olds have missed recommended dental visits

First Dental Visit at Aged 3?

First Dental Visit at Age 3?

First Dental Visit by the First Birthday!Within 6 months of eruption of first baby tooth

Critical period: 6 months – 3rd birthdayEruption of first tooth to last primary tooth

The Problem in Virginia: Access

• Few general dentists are comfortable seeing infants and toddlers

• Only 123 pediatric dentists practice in Virginia

– Most are in major metropolitan areas

• Only 25% of low-income children have seen a dentist before entering kindergarten

The Facts About Tooth Decay

• Tooth decay is the most common, chronic childhood disease

• NHANES: Decay rates increasing for 2- to 5-year-olds

• 2 years of age is too late

• Tooth decay is preventable

Early Childhood Caries (ECC)

• The presence of decayed, missing or filled tooth surfaces in a child younger than aged 6

• Begins soon after the teeth erupt

• Can result in a ‘cavity’ in 6 to 12 months

• Very rampant and destructive

• Costly to treat

– Children “pre-cooperative” because of age

– Sedation/general anesthesia often necessary to treat

Early Childhood Caries

Low-income preschoolers vs. more affluent peers

• 5 times the rate of tooth decay

• More extensive tooth decay

• 2 times the rate of dental pain

• Half as likely to access professional care

Consequences of Untreated Decay(in primary dentition)

• Increases risk of decay in permanent teeth

• Destruction of tooth structure

• Speech development problems

• Difficulty chewing poor weight gain/failure to thrive

Consequences (continued)

• Pain

• Inability to concentrate and learn

• Psychological problems

• Severe, life-threatening infections

Early Childhood Caries

A quality of life issue

Factors Necessary for Tooth Decay

• Oral flora: streptococcus mutans

– Acid-producing

– Acid-enduring

• Substrate: fermentable carbohydrates

• Susceptible tooth surface

• Frequency of exposure

Bacteria

• Transmissible

– Usually from parent/caregiver to child

• Window of infectivity: first 2 years of life

• Early colonization increases risk

• Creates a tenacious, highly complex biofilm

High Risk Behaviors for Infectivity

Feeding practices that transfer saliva:

• Sharing feeding utensils

• Testing temperature of foods or liquids

• “Cleaning” pacifier

• Pre-chewing food

Substrate: Fermentable Carbohydrates

• All sugars and complex carbohydrates

• Bacteria metabolizes carbohydrates, producing acid

• Acid de-mineralizes enamel, creating a visible “white spot”

• Frequency of acid attacks

Oral Flora of the Mother

• Impacted by sugar in diet

• High-sugar intake of mother results in:

– Higher levels of bacteria

– Increased acid endurance

– Higher risk of transmission to infant

• Primary prevention for baby begins with mother’s oral hygiene and diet

Susceptible Tooth Surface

• Directly related to fluoride exposure

• Widespread use of fluoride since 1950s

• Preventive effects of fluoride

• 2 types of fluoride exposure

– Systemic: pre- and post-eruptive benefits

– Topical: post-eruptive benefits

Mechanisms of Actions for Fluorides• Systemic effect

– Incorporates into tooth structure when small amounts are swallowed daily during tooth formation

– Saliva acts as fluoride reservoir to enhance remineralization process

• Topical effect

– Concentrates in outer enamel surfaces

– Plaque acts as a reservoir

– Interferes with bacteria’s ability to colonize and produce acid slows demineralization

• AAP resource (excellent!): I Like My Teeth

– http://ilikemyteeth.org/

Systemic Fluoride Sources• Fluoridated water

– Community water supplies

– Naturally occurring in well water

– Bottled water (certain brands)

– Filtered water (depends on filtration system)

• Fluoride supplements

– Recommended only for children at high risk

– Prescribed based on water test results

– Drops, liquid, tablets

• Fluoride in food and beverages/Infant formula

Topical Fluoride Sources

• Fluoridated water

• Fluoride toothpaste

• Professionally applied fluoride treatments

Fluoride Varnish• Safe, effective, and easy to apply on infants/toddlers

• Will remain on enamel surface for 1 – 7 days

• Properties eliminate risk of ingestion:

– Only a small amount is used

– Immediately adheres to outer tooth surface

– Slow release over time

• Currently used “off-label” for decay preventive

– FDA-approved as cavity liner / root desensitizer

Who May Apply the Varnish?Approved Providers in Virginia

PhysiciansDentistsNurse PractitionersPhysician AssistantsNurses (RNs, LPNs)Dental HygienistsDental Assistants___________________________

Level of supervision varies with training and licensing statutes.

When to Apply?

• Applications every 3 – 6 months, depending on risk

• Frequency coincides with well-child and WIC re-certification schedules

• Target age for reimbursement: 6 months – 3rd birthday

• Medicaid reimburses for 6 applications between 6 months and 3rd birthday

• Applications beyond the 3rd birthday will not be reimbursed but are appropriate in the absence of a dental home

Contraindications

• Ulcerative gingivitis

• Stomatitis

• Known sensitivity to colophonium resin

• Do not apply next to a large open soft tissue lesion

Medicaid Billing for Physicians

• Reimbursement from Standard FFS and Managed Care– Private carriers starting to cover service

• $21.66 per application of varnish (effective 7/1/17)• For children between 6 months and 3rd birthday

– Claims for 3-year-olds and older will be denied• CPT code: 99188 (effective 3/1/15)• Diagnosis code:

– New ICD10 code: Z29.3 (effective 11/1/16) • Verify/update provider and specialty codes with DMAS

for FFS• Need MCO credentials

4 Oral Health Components• Risk assessment

– Non-clinical risk factors

– Clinical risk factors

• Education for parent

– Nutrition

– Transmission of bacteria

– Daily oral care

– Fluoride

– Dental visits

• Fluoride varnish application

• Referral to local dentist

Materials Needed

• Gloves, mask

• Fluoride varnish (.25ml unit dose)

• 2 x 2 sponges (2 – 3)

• Disposable mouth mirror (optional)

Risk Assessment: Non-Clinical

Demographic factors

• Income

– Low-income status increases risk

• Age

– Disease is cumulative

• Ethnicity

– Cultural practices

• Special needs

Risk Assessment: Non-Clinical

• Individual risk factors

• Poor oral health of mother/sibling

• High sugar intake by mother

• High sugar intake by child

• Frequent snacking

• Inadequate fluoride exposure

• No dental home

• Low oral health literacy

Risk Assessment: Clinical

• Oral screening: not a definitive dental diagnosis

• Includes inspection of

– Teeth

– Gums

– Tongue

– Lips

– Inside of cheeks

– Palate

– Throat

Risk Assessment: Clinical(oral screening cont.)

• Purpose

– Early disease identification

– Increase awareness of parent as to importance of primary dentition

– Help establish a dental home

• Refer for age one visit regardless of screening findings

• Resource

– Smiles for Ohio video

– http://www.youtube.com/watch?v=84FUMRs8sfQ

Oral Screening and Varnish Application:Knee-to-Knee Position with Parent

Parent helps control arm and leg movement

Infant Young child

Oral Screening and Varnish Application

• Positioning infant or small child

• Parent holds child in “teddy bear” hug facing her

– Child’s legs wrapped around parent

• Position yourself in a knee-to-knee position with parent

• Parent leans child’s head back on your lap

– Parent uses arms to restrain child’s leg/arm movement

• Alternatives

– Exam table

– Child sits in parent’s lap (use this only when child of 2 –3 years of age is cooperative)

Oral Screening

Mouth mirror can be used to see the back sides of teeth

Oral Screening

Recognition of “white spot” lesions and decay

PlaquePlaque is visible only with “disclosing” solution.

Teeth will appear “fuzzy.”

Fluoride Varnish ApplicationKnee-to-knee position

Fluoride Varnish Application

• Open package, bend brush at neck, stir varnish

• Place varnish on “off-hand” with brush

• Demonstration resource: Smiles for Ohio video

– https://www.youtube.com/watch?v=zfdcjZ3ht9M

Fluoride Varnish Application

• Using gentle finger pressure, open child’s mouth

• Wipe teeth with gauze as you go

– The teeth do not have to be dry

• Retract lips as necessary, using fingers and gauze

• Apply a thin layer of varnish to all surfaces of teeth

• Once applied, varnish sets quickly

Post-Application Instructions

• Child should eat a soft, non-abrasive diet for the rest of the day

• Avoid hot foods/liquids that day

• Do not brush the child’s teeth until tomorrow

Anticipatory Guidance

• Nutrition

• Transmission of bacteria

• Daily home care

• Fluoride

• Dental visits

Nutrition

• Limit snacks to no more than 3 per day

• Juice and milk at mealtime only

• Water between meals

• Offer yogurt, cheese, fresh vegetables, and fruit

• Avoid sugary foods and liquids

Feeding Practices

• Avoid putting baby to bed with bottle/cup with anything except water

• Avoid spreading germs from one mouth to another

– Don’t share feeding utensils/toothbrushes

– Clean pacifier with soap and water, not saliva

• Use training cups carefully and temporarily

– Training/sippy cups are transitional

– Wean from bottle at aged 1

Daily Oral Hygiene

• Pregnant women and mothers– Brush at least twice/day with fluoride toothpaste

– Floss daily

• Infants– Teeth/gums wiped daily with washcloth or soft brush

– Use “rice-grain” size of fluoride toothpaste

• Toddlers– Brush teeth twice daily with “small pea-size” amount of fluoride

toothpaste

• Preschoolers– Brush teeth twice daily with “pea-size” amount of fluoride toothpaste

– Parents need to supervise and help with brushing

Fluoride Sources

• Children should have a regular source of fluoridated water, ideally community fluoridated water

• If bottled water is used, recommend “nursery” water

• Fluoride supplements are recommended only for those at high risk for caries and who lack regular access to fluoridated water.

• Use fluoride toothpaste daily

• Professionally applied fluoride from dentist or doctor or WIC clinic

Dental Visits

• Pregnancy

– Dental visits are safe and recommended

• First dental visit

– By the first birthday

– In the absence of dental home, the physician may be the first and only resource for oral screening and early disease identification

• Regular check ups at least every 6 months

Making a Dental Referral

• Establish relationships with local general and pediatric dentists

• Treat dental referrals as you would any other specialty referral

• Criteria:

– No dental home

– Signs of infection

– Visible decay

Making a Dental Referral

• Helpful websites

–Smiles for Children: https://www.dentaquestgov.com/state-plans/regions/virginia/

–Dental Health Program (VDH): http://www.vdh.virginia.gov/livewell/programs/oralhealth/

–Virginia Health Care Foundation: www.vhcf.org

Text4baby

• Free texting information service during

– Pregnancy

– First year of baby’s life

• National Healthy Mothers, Healthy Babies

• Provides timely health and safety tips

• Two ways to sign up

– Text ‘baby’ to 511411

– https://www.text4baby.org/

How to Implement

• Identify a coordinator

– Obtain supplies

– Software adaptations / electronic records

– Provide email to trainer

• Updates

• Follow up communication as necessary

ResourcesTraining new staff:

• http://va.train.org/ TRAIN ID: 1654433• Smiles for Life (modules 2 and 6)

– www.smilesforlife.org

• AAP Oral Health (modules 3, 5, and 6)

– http://www2.aap.org/ORALHEALTH/pact/index.cfm

• Other resources:– Virginia Department of Health

http://www.vdh.virginia.gov/livewell/programs/oralhealth/

– Maternal Child Health Bureau

www.mch.oralhealth.org

– American Academy of Pediatric Dentistry

www.aapd.org

Bright Smiles for BabiesFluoride Varnish Program

Summary

- Early childhood caries is a serious problem

- It is preventable!!!

- You have access to these high-risk childrenPreventing early childhood caries can have a

significant impact on the health of children.