Pediatricians may face challenges in implementing new U.S. Preventive Services Task Force recommendations that advocate the provision of oral fluoride supplementation to children in fluoride-deficient areas and fluoride varnish to all children by primary care clinicians.
The speed with which the recommendations are applied in primary care settings likely will depend on state support, training availability, and insurer cooperation.
Denver Health
Dr. Patricia Braun of 's Eastside Neighborhood Health Center poses with one of her patients.
"The updated recommendations are a very important step forward toward improving oral health in children through collaborative care," Dr. Lee Savio Beers of Children’s National Medical Center, Washington, said in an interview. However, "primary care providers will face a number of barriers in implementing these recommendations, including workflow and staffing issues, access to training, and adequate payment."
The USPSTF guidelines, published in early May 2014, recommend that primary care providers prescribe oral fluoride supplementation starting at 6 months for children whose water supply is lacking in fluoride and that they apply fluoride varnish to the primary teeth of all children starting at primary tooth eruption. The recommendations cite evidence that show fluoride varnish and oral supplements help prevent dental caries in children aged 5 years and younger, and that the treatments’ benefits outweigh the potential harms of fluorosis (Pediatrics 2014[doi:10.15425/peds.2014-0483]). The recommendations update 2004 guidelines in which only oral fluoride supplementation was recommended for children in areas with fluoride levels below 0.6 ppm in their local drinking water. That recommendation remains.
Whether the treatments will be covered by insurers will depend greatly on the state and the insurer. In nearly every state, Medicaid currently reimburses providers for the provision of fluoride varnish, said Dr. Patricia Braun, a pediatrician at Denver Health’s Eastside Neighborhood Health Center, and at the University of Colorado. She is a member of the American Academy of Pediatrics Section on Oral Health.
"From the publically insured perspective, it has already been decided that (such treatments) are important," Dr. Braun said in an interview. "The next challenge will be to get private insurers to do the same. As the task force recommendations indicate, all kids are at risk for caries, some more than others ... and all benefit from these services, including those (who) are insured by private organizations."
Payment for the recommended treatments is an issue that state agencies, professional organizations, and oral health advocates should start investigating now, Dr. Beers added.
Dr. Lee Savio Beers
"It will be important for pediatric primary care providers, pediatric dentists, regulatory agencies, and payers to work together in each state or region to develop an implementation plan in order to ensure the best intake," she said. "This is not something primary care providers should be expected to implement without this type of comprehensive support, including, but not limited to training and payment."
Training for pediatricians is already available in many states. Most jurisdictions have oral education programs that have been running for some time, Dr. Braun said, such as Colorado’s Cavity Free at Three and North Carolina’s Into the Mouths of Babes. Physicians also can utilize online programs such as Smiles for Life, a national oral health curriculum developed by the Society of Teachers of Family Medicine.
Dr. Beers recommends doctors visit the American Academy of Pediatrics’ website for more information about oral health training programs and resources, the Protecting All Children’s Teeth curriculum and the Bright Futures resources.
"We don’t need to reinvent the wheel," Dr. Braun said. "A lot has really been developed in the last decade, and we can now take advantage of the education" available about these services.
Dr. Anupama Rao Tate
Other challenges physicians may face in executing the recommendations include integrating the treatments into their routine practice, said Dr. Anupama Rao Tate, DMD, of Children’s National Medical Center, dentistry (oral health) department in Washington. For instance, physicians must decide whether the treatments should be provided as part of a well visit or independently.
In addition, electronic records may or may not have a place to track the services, Dr. Tate said. Conversations with parents also are necessary to help families understand why these services are being provided by their children’s primary care provider.
"Traditionally, dentistry has been separate from medicine," Dr. Tate said. Pediatricians are "going to have to change the mindset of parents and educate (them) as to why they’re doing something (pertaining to) dental health."