Questions about the safety of fluoride overall and fluoride varnish specifically “will come up” during discussions of oral health, Dr. Clark said. The only scientifically proven risk of fluoride is the development of fluorosis, which may occur if too much fluoride is ingested during the period of tooth and bone development, she said.
The small rise in plasma fluoride levels that can follow an application of fluoride varnish is comparable to ingesting a 1 mg fluoride tablet or brushing with fluoridated toothpaste, Dr. Clark said. Parents should be instructed not to brush the child’s teeth that evening or give any fluoride supplementation that day, if supplements are being used.
Not brushing teeth until the next morning also allows the varnish to stay on and continue depositing fluoride, she said. The child may eat, drink, and use a pacifier immediately after a varnish application. Hot, sticky, and crunchy foods should be avoided the same day.
The only contraindications to fluoride varnish are allergy to colophony/pine rosin, allergy to pine nuts, and ulcerative gingivitis/stomatitis or other open lesions. There are only three cases in the literature of side effects: one case of contact dermatitis and two cases of stomatitis. Colophony-free versions of fluoride varnish are available, Dr. Clark said.
Courtesy Dr. Rocio Quinonez
This child has severe caries.
Fluoride varnish is approved by the Food and Drug Administration as a cavity liner – not as a cavity prevention agent – but more than 110 studies and 40 clinical trials have documented its safety and effectiveness for cavity prevention, Dr. Clark reported. The 0.25 ml dose of varnish, which costs between $1 and $2, is the appropriate dose for children aged 4 years and under.Fluoride varnish is part of a bigger picture of oral health care in pediatrics – one that, first and foremost, involves “routinely asking if your patients have a dental home,” Dr. Clark said. The effectiveness of fluoride varnish is enhanced by regular discussions of oral health and counseling about risk factors for early childhood caries, such as frequent snacking and continual bottle or sippy cup use with fluid other than water.
Both Dr. Clark and Dr. Quiñonez urged pediatricians to take advantage of the parallels between obesity prevention and early childhood caries prevention nutritional messages (such as the risks of frequent juice and soda). And Dr. Clark suggested talking about bacteria and not just hygiene. “It sounds better to blame the evil bacteria than it does to blame poor hygiene, and that’s fine,” she said. “We can talk about how we’re going to keep the bacteria at bay.”
Dr. Quiñonez pointed out that children who were born premature or with low birth weights tend to have a higher prevalence of enamel defects and therefore are at greater risk of developing early childhood caries.
Courtesy Dr. Rocio Quinonez
This child has severe caries.
The AAP successfully advocated that fluoride varnish application be reimbursed as a separately reported service with use of the medical CPT code 99188. Use of the code to report fluoride varnish application by a physician or other qualified health professional took effect in January 2015. In some states, the dental code D1206 has been used with a V modifier specific to prophylactic fluoride administration for reimbursement through Medicaid and managed care. The modifier for use in ICD-10 is Z41.8.
“I’m in New York state, and we’ve been reimbursed $30 per fluoride varnish application (since 2009), and this includes risk assessment and counseling,” said Dr. Clark. “Some states pay in the single digits, and some pay in the high $50s.”
State by state information on payment and a host of practice tools and information on fluoride, fluoride varnish, and oral health risk assessment and counseling are available at the AAP’s Oral Health website. The site also provides links to each state’s AAP Chapter Oral Health Advocate who provides or coordinates education and training.