Using fluoride to prevent dental caries in children

The most common chronic childhood disease in the United States are dental caries, despite being a very preventable condition, particularly though the use of fluoride. Fluoride varnish application should be the standard of care in the pediatric primary care. A report in Pediatrics provided information on a number of things surrounding the procedure as well as general fluoride guidance.¹

Children can be exposed to fluoride through tap water that has been fluoridated, home administration, and professional application. Fluoride helps protect against dental caries in 3 ways: reduces enamel demineralization, promotes enamel remineralization, and inhibiting bacterial metabolism as well as acid production. For most children, fluoride toothpaste is the key way that children are exposed. Most toothpastes in the United States have a fluoride concentration of 1000 to 1100 parts per million. Because children aged younger than 6 years are more likely to swallow toothpaste, it’s recommended that parents supervise brushing. High-concentration fluoride toothpaste is available, but only by prescription from a dental health professional. It should only be used in children aged older than 6 years who can expectorate following brushing.

Fluoride varnish benefits all children, particularly those who don’t have regular access to a dental medical home. The fluoride concentration is 22,600 parts per million and the packaging for most products specify a dose. The current American Academy of Pediatric Dentistry recommendation is to apply the varnish to teeth every 3 to 6 months. Medicaid pays for fluoride varnish application in all 50 states. For patients who are covered by private health insurance, fluoride varnish application is a preventive service that requires no payment from the patient. The payment for the procedure should not be bundled with other routine preventive evaluation and management services. The American Academy of Pediatrics and Pew Center on the States have information covering coding, billing, and paying for fluoride varnish application.

The report closed out with a number of suggestions for pediatricians:

• Be familiar with how to assess a child for caries risk
• Recommend to parents that they initiate fluoridated toothpaste use when their child’s first tooth erupts, starting with a grain of rice-sized amount for children aged younger than 3 years and a pea-sized amount of toothpaste in children aged 3 to 6 years.
• Apply fluoride varnish at the recommended intervals and use the Current Procedural Terminology code 99188 for billing.
• Understand how to assess the fluoridation levels in a child’s primary drinking water source and determine if fluoride supplements are necessary.
• Be an advocate in the local community for water fluoridation.
• Know the indications for silver diamine fluoride and recognize the appearance of teeth that have been treated with silver diamine fluoride

Reference

1. Clark M, Keels M, Slayton R, Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics. 2020;146(6):e2020034637. doi:10.1542/peds.2020-034637