Oral health is an essential and integral component of a person’s health throughout his or her life¹ especially for school-aged children. Poor oral health and untreated infections can negatively impact the quality of life for school-aged children. Both the National Institute of Dental and Craniofacial Research and the National Education Association cite research showing American children miss 52 million hours of school each year due to oral health issues.

Strengthening the primary care delivery system, and investing in oral health disease prevention in the medical practice can contribute to improving the overall health of children, especially very young children. According to the 1999-2004 National and Nutritional Examination Survey (NHANES), approximately 42% of children ages 2 to 11 years have dental decay in their primary teeth. After decreasing from the early 1970s to the mid-1990s, the prevalence of dental decay in children has been increasing, particularly in young children ages 2 to 5 years.²

Dental decay is an infectious disease caused by a disruption in the normal balance of oral bacteria and overgrowth of cariogenic organisms (primarily Streptococcus mutans, S. sobinus, and lactobacilli) as a consequence of a diet high in carbohydrates and sugar.  Late stage interventions waste healthcare dollars and introduce significant risk to young patients requiring extensive, restorative, dental treatment, which often requires sedation in a hospital setting. To make a difference in the health of school-aged children it will take the disciplines of both the primary care providers and dental teams to reduce the burden of oral disease.

Developing a coordinated oral health care effort in Georgia between medical providers and dental providers can make a difference. The vast majority of infants and young children in Georgia see their primary care provider on a routine basis for well child care visits and immunizations. Thus, offering fluoride varnish to high risk children without access to a dental home through their medical providers can help to prevent and arrest dental decay. Evidenced-based studies indicate oral health prevention is cost-effective and saves children from pain and lost days of school.

In Georgia’s rural areas, and some urban areas, access to a dental practice often has significant barriers for children and adults.  We know oral health prevention works, but many of Georgia’s citizens with low oral health literacy lack the preventive services and proper oral home care habits to prevent diseases.  Poor oral health status exists in vulnerable populations, including diverse social and cultural backgrounds, low economic status, and low levels of education.

Many of the habits that contribute to higher levels of oral disease can be changed with support and education from medical and dental providers. While a dental practice provides an ideal dental home, when a dentist is not available the pediatric/family medical provider can fulfill the oral health care needs of their patients from a preventive approach until a dentist can be accessed and a dental home can be established. The members of the Georgia Academy of Family Physicians (GAFP) serve Medicare and Medicaid patients and could best reach these populations with oral health education and preventive fluoride varnish services for children.  Medicaid will also reimburse the fluoride varnish services provided for children.

Significant barriers to oral health services not only affect children, but adults as well. The Institute of Medicine (IOM) July 2011 report,Improving Access to Oral Health Care for Vulnerable and Underserved Populations, states that millions of Americans are not receiving dental care because of “persistent and systemic” barriers that disproportionately affect children, seniors, minorities, and other vulnerable populations.³ While cavities are the most common chronic disease for children and teenagers, older adults are at a higher risk of losing their teeth as they age. ²

Here are a few risk factors to consider when determining a patient’s need for anticipatory guidance, home care education, and fluoride varnish:

• Having decay is a risk factor for getting more decay. For example,  if a mother/caregiver has decay, more than likely the child will have decay; if a child’s siblings have had decay then the child has a higher risk for decay; and if a child has had decay in the past, then they will have a higher risk for more decay.
• Children in Women, Infants, and Children Supplemental Nutrition Program (WIC), Head Start, or Medicaid are at higher risk than are children in the general population due to lower income levels.
• Tooth location:

• For teens and adults: Decay most frequently occurs in the back teeth due to grooves and pits where plaque and food particles are most likely to collect.  View the back teeth for breaks in the enamel requiring restoration (cavitation) during a screening and assist the patient in getting an earlier referral before emergency services are needed.  Plaque and food debris in the grooves of back teeth suggests oral home care education is needed along with a referral to a dental home.

• For younger children, pre-school age, most decay begins on the top front teeth, right at the gum or gingival line.  It begins as a white decalcified area, progresses to brown, cavitates to small holes, and eventually breaks down the tooth.  If fluoride varnish is placed on the teeth in the earliest stage, the white decalcified state, and homecare instructions are given and followed, progression of the disease can be arrested, and often times reversed.

• For patients of all ages, recommend that the family monitor:

• Certain foods and drinks: Foods that cling to teeth for a long time, such as milk, ice cream, honey, table sugar, soda, raisins and other dried fruit, and sweetened desserts (dietary counseling)

• Frequent snacking or sipping: Steady snacks, sipping sweetened beverages, and sipping cups filled with fluids other than water can contribute to oral deterioration due to the constant acid exposure (dietary counseling).

• Timing and frequency of brushing: Teeth should be brushed soon after eating and drinking (oral hygiene instruction).

• Fluoride: Fluoride is a naturally occurring mineral that helps protect against cavities and can even reverse the earliest stages of tooth decay. Georgia has achieved recognition for community water fluoridation, with almost 97% of the population using community water receiving the benefits of fluoridation.  Many people with access to good tap water with fluoride, consume sweetened beverages and sports drinks instead of drinking tap water. If a patient can’t brush during the day – instruct them to swish with fluoridated water and swallow at night (preventive strategies and dietary).

• Dry mouth: Lack of saliva due to certain medications can reduce the buffering effect of saliva and natural protection against the acid manufactured by decay-producing bacteria. To counteract dry mouth, patients can use a fluoridated toothpaste and drink and swish with water often (education on pharmaceutical use).

• Gastroesophageal reflux disease (GERD) can erode teeth and contribute to significant tooth damage. Patients can use medication to control their acid reflux and its effects on their teeth (preventive services and prescriptions).

Fluoride Varnish for Infants and Children

• Why the recommendation for the first dental visit at age 1 year?  Fluoride varnish can reduce the primary maternal dental flora in the infant’s mouth (mother’s or caregiver’s transmission of bacteria to infant’s mouth), during eruption of the primary dentition. A multi-faceted approach includes ensuring the woman gets referred for dental services pre-, during, and post pregnancy and that the infant receives his or her oral health exam at age one.

• What is it? Most fluoride varnishes are lacquers containing 5% sodium fluoride in a pine plant resin base. Fluoride varnish provides a highly concentrated, temporary dose of fluoride to the tooth surface. The varnish holds fluoride close to the surface of the tooth for a longer period of time compared to other concentrated fluoride products.  Unlike the low-dose fluorides available over the counter, such as fluoride toothpaste, highly concentrated fluoride products, like fluoride varnish, must be applied by a healthcare professional in Georgia.

• How does it work? The fluoride varnish becomes concentrated in the outer enamel surfaces when applied after teeth erupt into the mouth. Dental plaque and saliva act as fluoride reservoirs to enhance the remineralization process. In addition, fluorides interfere with the decay-causing bacteria colonizing on teeth and reduce their acid production; thus, slowing demineralization.⁴ 

• How long does it stay on the teeth? The fluoride hardens on the tooth as soon as it comes into contact with saliva, allowing the high concentration of fluoride to be in contact with tooth enamel for an extended period of time, about one to seven days.

• Is it easy to apply? Varnish application is quick and easy. Inadvertent ingestion is also less likely, making it helpful for application with infants, toddlers, developmentally disabled individuals, or people with severe gag reflexes.

• The recommendations: The CDC (2001) and ADA (2006) recommend at least biannual application, at six-month intervals, to control dental decay in primary and permanent teeth for moderate, or high, risk children.

Several studies have shown that fluoride varnish is efficacious in reducing decay in the primary teeth of high-risk children. Varnish placement is quick and easy. Medicaid will reimburse medical practitioners for the oral health education and fluoride varnish application. Single dose fluoride varnish application packets make placement easy and efficient. By offering patients oral health guidance and fluoride varnish you can help your patients have a healthier smile.

Contact:  Carol Smith, RDH MSHA

Director of Oral Health

Georgia Department of Public Health

404-657-3138

Carol.smith@dph.ga.gov

References

1. S. Department of Health and Human Services. (2000). Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health. Retrieved from http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/Documents/hck1ocv.@www.surgeon.fullrpt.pdf

2. Barker, L. Dye, B., , Lewis, B. Smith, V. Tan, S., , Thornton-Evans G, et al. (2007). 1988-1994 and 1999-2004). Trends in oral health status: United Sates 1988-1994 and 1999-2004Vital Health Stat 11, (248), 1-92.

3. Improving Access to Oral Health Care for Vulnerable and Underserved Populations (2011 July 13). Retrieved from www.iom.edu/Reports/2011/Improving-Access-to-Oral-Health-Care-for-Vulnerable-and-Underserved-Populations.aspx

4. Fluoride Varnish: an Evidence-Based Approach Research Brief. (2007). Retrieved from http://www.kdheks.gov/ohi/download/Flvarnishpaper.pdf