From Medscape Medical News
February 28, 2011 — Children's dental health appears to improve when they get preventive services, including fluoride varnish, during medical appointments, according to a study published online today and in the March print issue of Pediatrics.
Children who got fluoride varnish, counseling, and dental assessments at least 4 times from their medical care providers were 17% less likely to have gotten fillings and other treatment for tooth decay at 6 years of age, reported researchers from the University of North Carolina, Chapel Hill. In addition, the trial found that those who received their initial treatment between 12 and 15 months of age were 49% less likely to require treatment for caries at age 17 months.
"There's plenty of evidence to show that fluoride varnish makes a difference," David Krol, MD, MPH, a pediatrician at the Robert Wood Johnson Foundation, told Medscape Medical News. "This study shows that it makes a difference in a medical office."
Although widespread use of fluoride has reduced the rate of caries in the general population, little progress has been made in young children; about 44% of US 5-year-olds have tooth decay, the researchers reported, citing earlier studies.
As a result, more and more pediatricians and family physicians are providing fluoride varnish, counseling, and dental assessments, beginning when teeth first appear, University of North Carolina Professor Gary Rozier, DDS, MPH, a coauthor of the study, told Medscape Medical News. "If there were enough dentists for all children to see a dentist within the first year, that would be ideal," he said. "But we're a long way from that."
About 40 state Medicaid programs have changed their reimbursement rules to pay physicians to provide this kind of care, Dr. Rozier said. In North Carolina, physicians can be reimbursed for applying varnish as often as every 2 months, with a limit of 6 applications before 42 months of age.
For the study, Dr. Rozier and his colleagues analyzed the records of all children aged 72 months or younger who were enrolled in the North Carolina Medicaid program from 2000 to 2006. The state allowed reimbursement for these procedures to all physicians in 2000 through a program called Into the Mouths of Babes.
In the program, physicians and physician extenders screen for caries, using a dental mirror and directional light and asking questions about children's oral health. They refer patients with obvious caries or risk factors to dentists.
Next, the physicians and physician extenders counsel the patients about hygiene and diet. Finally, they paint fluoride varnish onto the patients' teeth. The varnish hardens quickly and then gradually dissolves, leaving fluoride molecules in the enamel of the patients' teeth. It is more effective than many other fluoride applications because patients are less likely to swallow large amounts, it lasts longer, and it is an easy procedure to perform, explained Dr. Rozier.
"Having done it, I know it doesn't take that long," agreed Dr. Krol, who previously worked as a pediatrician at the University of Toledo, Ohio. "I think there are ways of making it work without eating into too much of the time that pediatricians have available."
The researchers found that 194,730 children got no preventive oral care through the program. Another 55,561 got the care in 1 visit, 37,353 in 2 visits, 21,398 in 3 visits, and 13,424 in 4 or more visits. To measure the benefits, the researchers totaled the number of treatments each group received for caries, such as restorations.
They found that those who had the most frequent sessions of preventive care, and those who were youngest, had the fewest caries treatments. From 49% at 17 months of age, the estimated reduction in caries treatments declined to 17% by age 72 months in those children who had at least 4 visits with the preventive care.
There were no statistically significant benefits for those children who received preventative care fewer than 4 times.
The benefits appeared to be smaller in this study than in previous randomized controlled trials. These trials found a significant benefit beginning with even a single varnish application.
The North Carolina researchers wrote that one reason they found a lower benefit may be that some of the children in their study had not gotten dental care early in life and already had caries.
In addition, the outcome measured in this study — treatment for caries — is only an indirect indication of caries. Some physicians in the program may have referred children for treatment who would not otherwise have gone to a dentist at all, the researchers wrote.
However, the benefits of more frequent treatments should not be ignored, said Dr. Rozier. "You have to work to get these services to kids at a young age and apply them regularly until they age out of the program. It's like immunization; you have to follow a schedule."
The study was supported by grants from the National Institute of Dental and Craniofacial Research of the National Institutes of Health. One author received a National Research Service Award from the Agency for Healthcare Research and Quality. Dr. Krol as well as Dr. Rozier and the other study authors have disclosed no relevant financial relationships.
