An expert panel commissioned by the American Dental Association's Council on Scientific Affairs recommends fluoride varnish to protect teeth from dental caries in children ages 0 to 6 years. Nurse practitioners (NPs) can apply fluoride varnish during sick or well visits to help decrease the amount of cavities in young children and in most states can bill Medicaid for the application. While fluoride varnish is easily applied to teeth, it can be distressing to a child. Gaining a child's cooperation through proper positioning, distraction, and play is pivotal during the application process and allows the healthcare provider the ability to complete an oral exam for early detection of problems. This article will provide strategies to allow healthcare providers success in examining the teeth of young children during application of fluoride varnish and have children leaving with a smile on their faces.
The most common infectious disease of children is dental caries.1–3 Cavities in preschool children increased significantly in the last decade when compared to older children.4 The CDC reports that “While percentages of untreated cavities have declined from 1971 to 1974 (25.0% in children ages 2 to 5 and 54.7% in children ages 6 to 19), data for the most recent time period still show high levels of untreated cavities: 19.5% in children ages 2 to 5 and 22.9% in children ages 6 to 19.”5
Early childhood caries (ECC) is defined by the American Academy of Pediatric Dentistry (AAPD) as the presence of one or more decayed, missing (as a result of caries), or filled tooth surfaces in any primary tooth in a child 71 months of age or younger.6 Children of this age group visit their primary care provider on a regular basis for well-child physicals and sick visits. The AAPD and the American Academy of Pediatricians (AAP) recommend that medical primary care providers include the following oral health prevention strategies during these appointments: perform periodic risk assessments to determine the child's relative risk of developing dental caries7; provide anticipatory guidance to parents about oral hygiene, diet, and fluoride exposure; apply appropriate preventive therapies, such as fluoride varnish; and help parents establish a dental home for their children by 12 months of age.8 (See AAPD Caries-risk Assessment Tool.)
ECC develop in young children who use sippy cups or baby bottles inappropriately and have poor nutrition with a history of eating frequently or eating the wrong foods (see Some foods that impact dental health).9 The process of decay is mostly influenced by sugars that can be fermented by the bacteria in the mouth, causing a lower pH or acidic environment.10 This environment works on deteriorating the enamel of the tooth, and demineralization will incite a cavity. Caries in the primary dentition leads to the same in permanent teeth.11
Another source of caries, aside from poor nutrition choices, is infection. Mothers who pick up their child's pacifier and put the pacifier in their mouth to clean it off may inadvertently pass on the bacteria, mutans streptococci, which cause dental caries. Along with passing the infection by saliva and mouth kissing, the frequency of eating significantly increases the presence of mutans streptococci.12 The constant change of the acidity of the mouth's saliva will cause wear down of the protective enamel setting up the possibility of decay. A human's saliva has the ability to cause remineralization of the tooth's enamel. Eating foods that keep the acidity of saliva high continues to cause demineralization and the potential for dental caries. The more the teeth are bathed in anything other than water or healthy saliva, the greater the chance of demineralization. Despite the understanding of the risk factors associated with caries in early childhood, caries remains one of the largest untreated conditions in preschool children.13
High-risk children between the ages of 6 months and 3 years of age were the first group of children recommended to have fluoride varnish applied to their teeth to prevent dental caries.14More recently, dentists suggest all children could benefit from using fluoride varnish to prevent dental caries. Fluoride varnish has been professionally applied for 30 years in Europe. An application may inhibit or even reverse the initiation and progression of dental caries by inhibition of the demineralization process and promotion of remineralization of tooth enamel.15 Due to ease of use and low risk of fluoride toxicity, fluoride varnish is ideally suited for topical application to the teeth of preschool children.16
This sticky liquid is easily painted on the teeth where it hardens and remineralizes the tooth enamel. Early prevention and treatment of dental caries in preschool children has a long-term impact on health. Treating caries before pain occurs relieves suffering and limits infection, which may lead to brain abscess and death.17 Therefore, new recommendations from the expert panel commissioned by the American Dental Association's Council on Scientific Affairs advocates for the early and consistent use of fluoride varnish treatment. These applications can prevent early caries and permit detection of early complications of dental disease in children of any age, especially for those who have special healthcare needs that limit their attention span and/or cooperation.18 Applications should be completed at least twice a year for 30% to 40% reduction in dental caries.5 Although adverse reactions from fluoride varnish are rare and can be resolved by thorough brushing, the following have been noticed: dyspnea in patients with asthma, and if the application is extensive, there may be edematous swelling or nausea.19
Performing an oral health exam on a young child can be challenging and is too often omitted during physical exam. Parents who have taken their young children to the dentist often report that the dentist informs them to bring the uncooperative child back in a year or two. This delay can be detrimental to normal, healthy development of adult teeth; it can also increase the risk of infection, some of which are serious enough to cause death.17
Oral health has been linked to physical health, social acceptance, and well-being. During these early years of physical growth, appropriate nutrition is essential. If chewing is painful, children will refuse to eat crunchy fresh fruit or vegetables because they cause too much discomfort. Socially, children are sensitive to being different from others. If teeth are decayed or eroded, it sets them up for social bullying. Normal eruption of teeth permits children successful language development. Proper speech, sturdy teeth, and attractive smiles permit children greater access to their social worlds and help them achieve physical health and social acceptance.
To feel comfortable during any procedure, children require simple explanations and demonstrations of procedures while in the presence of their parent/guardian.20 Healthcare providers are so often focused on the child that they sometimes fail to assess the needs of the parent or guardian. An understanding of the procedure for both the child and parent must be determined before beginning any procedure. Educating the caregiver on the importance of attaining a fluoride varnish application for each child on a regular basis is paramount to initiating remineralization of the enamel and prevention of cavities.
One approach to education is to advise parents on how to prevent spreading the cavity-causing bacteria. Health providers may recommend that older individuals with dental caries chew gum containing xylitol three to five times daily. This natural sugar alcohol disturbs protein synthesis and inhibits the growth of Streptococcus mutans. It actually interferes with the in vitro growth of mutans streptococci and does not become fermented. This keeps the saliva at a healthier pH level and does not contribute to demineralization of the tooth enamel.21
Children about to have fluoride varnishing must be still long enough for the varnish to be applied. Distraction is a common technique used with children during a procedure to shift the focus to a pleasant experience—one that is not frightening. However, the successful use of a distraction technique for the child often depends on the level of anxiety of the parent/guardian. Dahlquist and Pendley reported children who failed to respond to distraction had parents who were significantly more anxious than a comparison group of parents of distractible children during a procedure (this particular study focused on parents of children undergoing cancer treatment therapy).22 Parental attitudes toward oral exams of children were also more favorable when the least-aggressive techniques for holding the child were employed versus when physical restraint and drugs were used.23 Parental support before and during the exam is key to being able to varnish a child's teeth and perform a comprehensive oral exam.
Establishing an effective, cooperative relationship between the parent/guardian and the clinician is an essential first step. Healthcare professionals should be confident and positive when approaching the parent/guardian and child. Information regarding the child's diet, use of sippy cups, bottles, or pacifiers should be determined. A nonjudgmental approach is needed to encourage cooperation and to teach the child and parent how to make healthful choices that produce positive oral health outcomes.
Next, provide verbal information while demonstrating the procedure using a doll or stuffed animal with teeth. According to Piaget's stages of development, youngsters in the preoperational period (2 to 7 year of age) enjoy engaging in symbolic thought.24 Children are attentive during the step-by-step demonstration. Encouraging the child to demonstrate the varnishing procedure on the doll reassures the child that it is easy and not painful. If the child is hesitant, have the parent perform the procedure on the doll. Ask the child to mimic the doll's wide open mouth and to try to hold it open for a long time like the model. This strategy enhances the healthcare provider's chance to provide a good oral screening and application of fluoride varnish.
Children discover the world by using all of their senses. Give children the opportunity to touch items being used in the exam. Demonstrate how soft the gauze is by allowing them to handle it. When putting on gloves, use the opportunity to talk about not sharing germs. The flexibility of the small paint brush can be shown by depressing it on the gloved hand. Children are encouraged to smell the fluoride varnish, which is available in a bubble gum flavor. Children like being told they have beautiful, healthy teeth, and this will help them keep their teeth super strong. Finally, before beginning the exam and varnishing, it is important to verify all questions have been answered for the child as well as the parent. The list below points out key educational points to discuss with caregivers and preschool children:
- Have a personal toothbrush that no one else uses.
- Brush at least 2 minutes twice a day (after breakfast and before bed) with an adult brushing the child's teeth before bedtime until age 7.
- Use a smear of fluoride toothpaste on a soft toothbrush until child spits well.
- Once able to spit well and not swallow, increase fluoride paste to a small pea size or the size of the child's smallest fingernail.
- Drink water after eating crackers or sweets to rinse off the teeth.
- If a toddler carries a sippy cup around while playing, fill with water only.
- If going to bed, fill bottles or sippy cups with water only.
- When nursing an infant, the mother should take the baby off the breast once asleep.
- Limit fruit juice to 4 oz (120 mL) daily, three cups of milk, and otherwise, drink water.
- Encourage fresh vegetables and protein-rich foods as snacks, and limit candy.9
These important items can be woven into conversation so that both the caregiver and child will take away good healthful information.
Music has long been recognized as an intervention that has calming and soothing properties.25 Having a CD of age-appropriate children's music playing in the room can be calming and another beneficial distraction.
To provide the application of fluoride varnish on an infant with only a few teeth, the procedure is quick and easy if done while positioning the child on the adult's lap. The parent can loosely pin the child's arms while giving them a soft squeeze. This keeps little hands out of the way. Any child that is hesitant to cooperate may be placed in the following position: Have the parent hug the child, holding them chest-to-chest with the child's legs on either side of the parent's lap. The child sits in the adult's lap that is in a knee-to-knee position with the clinician. The child is laid back with their head resting in the lap of the examiner. Playing peek-a-boo as they lie back and not immediately beginning the exam allows the child time to feel secure and ultimately allows for a more thorough exam.
Many of the preschoolers prefer to stand close to their parents. If multiple children are present, apply to the most cooperative first so they may set a good example. Colorful wall hangings and mobiles on the ceiling above the exam area are an easy distraction. Adorning the ceiling with small stuffed stars or butterflies gives the child something to focus on while raising the chin to view the upper teeth and gums.
Ask the child to open his or her mouth wide. The oral exam is conducted before varnishing the teeth, as the fluoride hardens when it meets with saliva. Inspect the oral mucosa, including the tongue and buccal lining, for color and the absence of lesions. If there is an open lesion of the mucous membrane, the procedure should be postponed. The oral cavity skin and tongue should be moist, pink, and free of lesions. If the gums appear red and inflamed, the provider should ascertain if this is a pathogenic process or merely teething. Teething is obvious when looking at teeth slightly protruding through the gum or realizing the age of the child. The surface of each tooth's enamel needs to be visualized for irregularities in smoothness, luster, or variation in color. Visualize along the gum line for accumulation of plaque, which cannot be removed and is often a yellow or light brown color. There is a greater risk that caries are developing under the plaque. It is essential that the child be seen by a dentist to have the plaque removed. Teeth that have visible cavities, dark brown areas on the teeth with or without erosion, teeth appearing transparent and lackluster, and those with white spots, which can be the beginnings of dental caries, should be evaluated by a dentist. Even though a series of fluoride varnish application may be effective in arresting early active enamel pitting and lesions in any primary dentition, parents are reminded that this is an oral screening, and seeing a dentist for positive diagnosis and treatment of cavities is essential.15
At the end of the visit, home instructions are given that include no brushing until the following morning and a soft diet for the remainder of the day; both allow the fluoride varnish to absorb into the enamel. Families are also informed that the American Dental Association, AAPD, the American Association of Public Health Dentistry, and the AAP recommend every child should have a “dental home” by 12 months of age.8 Families should receive a dated card documenting the fluoride application to share with their dental provider.
Primary care providers, such as pediatricians, family practice physicians, pediatric NPs, and family NPs should not miss any opportunity to diminish the disease process of dental caries. Taking time to shape the oral health knowledge, attitudes, and behaviors of children and their families is time well spent. With proper education, these primary care providers can assess oral health and apply fluoride varnish to very young children.13
In over 40 states, primary care providers can bill Medicaid for reimbursement. In Ohio, for example, the Medicaid reimbursement will cover as much as $15 a treatment, which is meant to cover both varnish and the labor involved in the treatment. For children who are under 3 years of age and present for a sick visit or a well-child physical exam are eligible for this reimbursement. A span of 180 days (minimum) between applications must occur before payments can be reimbursed. Each state may have different Medicaid reimbursement policies, so one should determine state policies for particulars.26
This article summarizes the current literature on the status of children's oral health and fluoride varnish applications, caries and their chief determinants, methods to successfully apply fluoride varnish to younger children, including distraction, teaching, play, imitation, exploration, and information about Medicaid reimbursements. Taking the brief time to provide fluoride services to the youngest children will improve their overall health, particularly their oral health, and encourage the opportunity to find a dental home, which will provide consistent care of the growing child's teeth.
The procedures described were explored through grant number P3011150 received from the W. K. Kellogg Foundation obtained by the University of Akron; Improving Oral Health of Poor and Low Income Pregnant Women, Mothers, and Children Up to Five Years Old: A Pilot Intervention at Urban and Rural WIC Program Sites in Northeastern Ohio. Part of the objective of this grant is to expand the dental workforce capacity to aid in the reduction of young children's cavities. NPs have the opportunity to improve the oral health of their patients by using this simple procedure to attain a good oral health exam.
Some foods that impact dental health
Foods that cause tooth decay (if consumed too often or they stick to the teeth)
- Breads, crackers, cereal
- Chips or pretzels
- Dried fruit
Foods that do not cause tooth decay
- Nuts (children over age 3)
- Sugarless gum/candy
Foods that prevent or reduce acid production if eaten after sugary or starchy foods
- Swiss cheese
- Monterey Jack cheese
- Cheddar cheese
- Xylitol gum
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