Open Mouth, Open Mind: Expanding the Role of Primary Care Nurse Practitioners

      Abstract

      Oral health is essential to overall health at any age, although in children it is particularly important because poor oral health can have a deleterious effect on deciduous and permanent dentition. For decades, oral health providers have urged primary care providers to incorporate oral health assessment, risk factor identification, parent education, and preventive therapy into routine well-child visits. Despite recommendations from various professional associations and governmental organizations, the incidence of dental disease in young children remains relatively unchanged. Although the literature has clearly demonstrated that preventive care treatments, such as the application of fluoride varnish performed in the primary care setting, improve oral health in children, very few primary care providers include oral health services in their well-child visits. The purpose of this article is to reduce the barriers and knowledge gaps identified in recent pediatric oral health research and educate primary care nurse practitioners on the application of fluoride varnish to reduce the risk of the development of dental caries in young children.

      Key Words

      • 1.
        Summarize the definition and epidemiology of early childhood caries.
      • 2.
        Analyze the most current evidence-based recommendations for prevention of early childhood caries.
      • 3.
        Utilize risk factors for early childhood caries to guide oral health education for families.
      • 4.
        Identify signs of early childhood caries indicating the need for referral to a dentist.
      • 5.
        Promote the integration of fluoride varnish use into the primary care setting.
      Dental caries was identified as a significant yet preventable health problem in young children generations ago. To address this issue, in 1978 the American Academy of Pedodontics (since 1984, also known as The American Academy of Pediatric Dentistry [AAPD]) and the American Academy of Pediatrics (AAP) released a joint statement, Nursing Bottle Caries, to recommend that parental education be aimed at discontinuing baby bottle use in infants as soon as possible after the first birthday (
      American Academy of Pediatric Dentistry
      Policy on early childhood caries (ECC): Classifications, consequences, and preventive strategies. American Academy of Pediatric Dentistry Reference Manual V 36/NO 6.
      ). According to the National Health and Nutrition Examination Survey (NHANES) data from 1988-1994, the prevalence of dental caries was 24% among children ages 2 to 5 years, making it the most common chronic disease in childhood (five times more common than asthma;
      • Moyer V.A.
      on behalf of the US Preventive Services Task Force
      Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
      ). In 1999, upon recognizing that this disease was multifactorial because it was seen in children who did not use baby bottles, dental experts and organizations agreed to cease using the term “nursing bottle caries” and settled upon common definitions of dental caries in young children. Early childhood caries (ECC) is defined as “one or more decayed (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces” in any primary tooth in a child younger than 6 years. Severe childhood caries is defined as any sign of caries on a smooth surface of a tooth (noncavitated or cavitated) prior to 3 years of age (
      American Academy of Pediatric Dentistry
      Policy on early childhood caries (ECC): Classifications, consequences, and preventive strategies. American Academy of Pediatric Dentistry Reference Manual V 36/NO 6.
      ). In 2000, the Surgeon General's Report on Oral Health included information on ECC to increase public awareness, and at the same time the Centers for Disease Control and Prevention (CDC) made a goal in the Healthy People 2010 initiative, setting the prevalence threshold of ECC at 11% for children ages 2 to 5 years as a health determinant. Unfortunately, this goal was not met, and there was actually a 33% increase of caries in this population. The most current NHANES data from 1999-2004 showed a prevalence of ECC in 28% of children (
      • Moyer V.A.
      on behalf of the US Preventive Services Task Force
      Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
      ). Furthermore, the survey found that 72% of tooth surfaces in children ages 2 to 5 with caries were untreated (
      • Tinanoff N.
      • Reisine S.
      Update on early childhood caries since the Surgeon General's Report.
      ).
      During the past two decades, the AAPD has made eight revisions to the original statement on “baby bottle” tooth decay. Today this document is entitled Policy on Early Childhood Caries (ECC): Classifications, Consequences, and Preventive Strategies and was last revised in 2014 (
      American Academy of Pediatric Dentistry
      Policy on early childhood caries (ECC): Classifications, consequences, and preventive strategies. American Academy of Pediatric Dentistry Reference Manual V 36/NO 6.
      ). With each revision, current research data were evaluated and new caries prevention strategies were implemented. Despite all of the recommendations, as well as innovative products and services, the prevalence of ECC has remained relatively unchanged. Several of these preventive strategies called for primary care providers to incorporate oral health services, including oral assessment, risk factor evaluation, systemic fluoride supplementation, and topical fluoride varnish application, into the well-child visit. According to the AAP, approximately 90% of infants and 1-year-olds have seen a primary care clinician, yet fewer than 2% have seen a dentist (
      • Clark M.B.
      • Slayton R.L.
      Section on Oral Health
      Fluoride use in caries prevention in the primary care setting.
      ). Thus the primary care clinician is positioned as an obvious resource for recommended services such as fluoride varnish application in infants and children. It is estimated that only 4% of primary care practices perform fluoride varnish application, with training deficits cited as a major barrier (
      • Moyer V.A.
      on behalf of the US Preventive Services Task Force
      Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
      ). In 2014, the U.S. Preventive Services Task Force (USPSTF) published simplified recommendations to further encourage primary care clinicians to identify risk factors, prescribe systemic fluoride supplementation if indicated, and apply fluoride varnish to the primary teeth of all children 5 years or younger beginning at the eruption of the first primary tooth (
      • Clark M.B.
      • Slayton R.L.
      Section on Oral Health
      Fluoride use in caries prevention in the primary care setting.
      ,
      U.S. Preventive Services Task Force Independent Expert Panel
      Prevention of dental caries in children from birth through age 5 years: U.S. Preventive services task force recommendation statement.
      ).
      The primary care clinician is positioned as an obvious resource for recommended services such as fluoride varnish application in infants and children.

      Early Childhood Caries

      ECC is a chronic, infectious disease that is orally transmitted from family members to infants and young children. This microbiological process begins silently with the accumulation of plaque on tooth surfaces. Plaque is a type of biofilm—that is, a collection of bacteria and other microorganisms mixed with saliva that forms a sticky substance that clings to teeth (
      • Mahat G.
      • Lyons R.
      • Bowen F.
      Early childhood caries and the role of the pediatric nurse practitioner.
      ). With the consumption of dietary carbohydrates such as sucrose, glucose, fructose, and cooked starch, the cariogenic bacteria in the plaque, mainly Streptococcus mutans, thrive and multiply. These fermentable carbohydrates, once metabolized by the bacteria residing in the plaque, form an acid that can rapidly demineralize the tooth enamel. Fortunately, this process can be reversed through remineralization of the tooth surfaces with the frequent application of fluoride by means of a fluoridated dentifrice (toothpaste) or application of a fluoride varnish and the ingestion of fluoridated water or fluoride supplements. The advantage of multiple fluoride sources is that the effects on the tooth surface are cumulative. Saliva has protective properties, and when adequate fluoride is available, it bathes the teeth with fluoride and calcium and other minerals to counterbalance the mineral loss from the aciduric bacteria in the plaque. However, if fluoride exposure is not adequate from any single source or combination of sources, demineralization will occur more rapidly than remineralization and cavitation will likely result.
      The first sign of ECC is the appearance of white spots on the surface of the tooth indicating a loss of mineral on the enamel surface. The lesions can appear on any tooth surface but often appear along the gum line of the maxillary primary incisors and first molars, where plaque often accumulates. They are best visualized by drying the teeth with gauze and using a good light source. At this point, EEC is still reversible if the causative factors are identified and minimized. Application of fluoride varnish to the teeth, proper home care, lessening the frequency of carbohydrate consumption, and caregiver education to further reduce risk factors may result in a complete eradication of the carious lesion. All children identified as having white spot lesions are considered to have ECC and need immediate referral to a dentist (Figure 1). If the process is not counterbalanced with remineralization, eventually the enamel will become cavitated, allowing rapid destruction of the dentin and pulp. Once it has progressed to this point, restoration or possibly extraction of the tooth is required (Figure 2).
      Figure thumbnail gr1
      Figure 1Stages of early childhood caries.
      Used with permission. © 2015 Kowolik. This figure appears in color online at www.jpedhc.org.
      Figure thumbnail gr2
      Figure 2The caries process.
      Reprinted with permission by
      • Berg J.H.
      The marketplace for new caries management products: dental caries detection and caries management by risk assessment.
      . © 2006 Berg; licensee BioMed Central Ltd. This figure appears in color online at www.jpedhc.org.
      ECC has many short- and long-term sequelae that affect not only the child but also the family and society. If ECC is not treated appropriately, the infection can spread into the soft tissues, causing abscess or facial cellulitis with the potential of systemic infection, sepsis, and, in rare cases, death (). ECC can also cause speech problems from premature tooth loss and can impair growth from nutritional deficiencies as a result of eating difficulties. Untreated ECC can cause pain leading to missed school days and thus decreased school performance. It is estimated that children miss 51 million school hours each year, and parents also miss many work hours and income as a result of ECC (
      • Moyer V.A.
      on behalf of the US Preventive Services Task Force
      Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
      ). No data are available for the number of day care hours missed as a result of ECC, but these hours missed are assumed to be significant. Beyond the physical pain associated with ECC, emotionally, children may experience an altered appearance and diminished self-assurance (
      • Chou R.
      • Cantor A.
      • Zakher B.
      • Mitchell J.P.
      • Pappas M.
      Preventing dental caries in children <5 years: Systematic review updating USPSTF recommendation.
      ). At the societal level, the cost of treating ECC is approximately 10 times higher than the cost of prevention. Additionally, young children with ECC or severe ECC are relatively more likely to be treated in the emergency department for pain management or to require dental treatment in a hospital surgical setting if the damage is extensive. Because many of these children are uninsured and/or come from a poor household, society absorbs these costs (
      Association of State and Territorial Dental Directors
      Best practice approach: Prevention and control of early childhood tooth decay.
      ). All of these short- and long-term effects of ECC support the need for action at the primary care level by nurse practitioners (NPs).
      At the societal level, the cost of treating ECC is approximately 10 times higher than the cost of prevention.

      Risk Factors

      It is difficult to predict which children will develop ECC. Prior research has identified many risk factors for ECC, and risk factor assessment tools have been developed. However, no single risk factor has been found to be more significant than another in causative effects of ECC (
      • Moyer V.A.
      on behalf of the US Preventive Services Task Force
      Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
      ). According to
      • Moyer V.A.
      on behalf of the US Preventive Services Task Force
      Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
      , past and current risk factor assessment tools have not been proven to be valid in differentiating high risk from low risk of ECC in children. The AAP endorses the USPSTF recommendation to abstain from utilizing risk assessment stratification to determine the need for fluoride varnish but rather to use identified risk factors as educational points for caregivers and children (
      • Chou R.
      • Cantor A.
      • Zakher B.
      • Mitchell J.P.
      • Pappas M.
      Preventing dental caries in children <5 years: Systematic review updating USPSTF recommendation.
      ). It is important to recognize that some risk factors are not controllable with preventive measures. Therefore, NPs must be cognizant of the fact that all children are at risk for ECC even in the absence of known risk factors. The end goal is to maintain balance between the risk factors that can be modified while enhancing the factors amenable to protective measures. This goal can be achieved through parental and caregiver education, along with fluoride varnish application, which is now the recommended standard in every well-child visit for all infants and children younger than 6 years (
      • Moyer V.A.
      on behalf of the US Preventive Services Task Force
      Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
      ).

      Risk Factor Modification

      ECC is preventable and possibly reversible by promoting basic primary prevention efforts (
      American Academy of Pediatric Dentistry
      Policy on early childhood caries (ECC): Classifications, consequences, and preventive strategies. American Academy of Pediatric Dentistry Reference Manual V 36/NO 6.
      ). Education about risk factor modification is critical in prevention of ECC. Because caries develop in many children prior to their first birthday, proper oral care regimens, healthy dietary habits, and adequate fluoride exposure should begin with the mother during the prenatal period or shortly after delivery (
      • Marrs J.
      • Trumbley S.
      • Gaurav M.
      Early childhood caries: Determining the risk factors and assessing the prevention strategies for nursing intervention.
      ).

      Oral Hygiene

      A proper oral health regimen is one of the simplest home care measures for the prevention of dental decay at any age. Research has shown that mothers without caries and families who receive recommended dental care are less likely to have children with ECC (
      • Berger C.
      • Bachman J.
      • Casalone G.G.
      • Farberman S.
      • Fisch A.
      An oral health program for children.
      ). Conversely, mothers and other family members with dental caries are more likely to be colonized with S. mutans and may unknowingly transmit the cariogenic bacteria to the infants by “cleaning” pacifiers in their mouths, kissing, or sharing beverages. It is advised that all pregnant women seek professional dental care. Those found to have caries should have affected teeth repaired and use measures aimed at reducing bacterial colonization, such as chlorhexidine rinses and xylitol gum or mints, prior to the baby's birth (
      • Tinanoff N.
      • Reisine S.
      Update on early childhood caries since the Surgeon General's Report.
      ). If these measures are not accomplished, the infant runs the risk of ECC when the first tooth erupts and the bacteria have a new site to proliferate and destroy the delicate tooth. Once bacterial colonization with S. mutans occurs, it can be difficult to eradicate, thus making prevention strategies critical to maintaining oral health.
      All infants need an oral health regimen from birth. Before the teeth erupt, it is adequate to clean an infant's mouth with a wet soft cloth to simply wipe milk curds or other debris from the tongue and gums. This routine helps establish a good habit from day one. Once the first tooth appears, it is time for twice daily brushing with a small, soft toothbrush and fluoridated toothpaste, which removes the bacteria-laden plaque from the teeth and exposes the teeth to fluoride. Parents should apply the toothpaste to the brush instead of to the tooth to reduce the amount used and decrease the likelihood of ingesting too much toothpaste. Children younger than 3 years should use a smear of paste on the brush that is the size of a grain of rice, and children older than 3 years should use a pea-sized amount. All children younger than 8 years should have their teeth brushed by an adult because these children lack the dexterity to brush their own teeth. Children should be encouraged to expectorate the toothpaste rather than swallow it and to avoid rinsing after brushing. When there is little or no space between the child's teeth and toothbrush bristles cannot effectively be placed to remove food and dental plaque, it is time to add flossing to the daily dental care regimen at home. Over-the-counter fluoride rinses are generally not advised until a child is 6 years old and able to “swish and spit” without swallowing the rinse. Over-the-counter rinses should not take the place of toothpaste because the amount of fluoride they contain is dramatically less than that found in toothpaste. The American Dental Association recommends that all parents establish a dental home for their child within 6 months of the eruption of the first tooth or by 1 year of age. However, because of a lack of pediatric dentists or general dentists reluctant to treat very young children, lack of dental insurance, and the associated cost of dental care, many children do not see a dentist until much later, and often ECC is already present (
      • Smith L.
      • Riter D.
      Medicaid reimbursement and training enable primary care providers to deliver preventive dental care at well-child visits, enhancing access for low-income children.
      ).

      Dietary Habits

      It is well known that diets high in fermentable carbohydrates (e.g., cookies, candy, bread, bananas, and cereal) contribute to the development of dental decay in all ages. Unfortunately, many young children are picky eaters and have a penchant for these foods. They may also have eating habits such as “grazing” on food and beverages all day and taking a bottle or Sippy cup to bed with them. These factors, when combined, can be a recipe for rampant ECC. Parents and caregivers should be educated to offer children a variety of nutritious foods that are low in fermentable carbohydrates and to foster healthy eating habits, including scheduled meals and snacks during the day and avoidance of ad libitum beverage consumption, including fruit juice. This approach allows time for the pH of the saliva to return to neutral between meals, thus allowing remineralization of the teeth to occur. Constant exposure of the teeth to food and beverages, even water, inhibits this natural cycle, and the salivary pH remains low, thus supporting the metabolism of aciduric S. mutans, which increases the demineralization process and degradation of tooth enamel and promotes the progression of dental caries (
      • Kagihara L.
      • Niederhauser V.P.
      • Stark M.
      Assessment, management, and prevention of early childhood caries.
      ). Because salivary production is lower at night and therefore less protective, infants and children should not be given a bottle or Sippy cup of milk or juice before bed or during the night. For older infants, ad libitum breastfeeding through the night should be avoided as well (
      • Clark M.B.
      • Slayton R.L.
      Section on Oral Health
      Fluoride use in caries prevention in the primary care setting.
      ).

      Fluoride

      Fluoride, a naturally occurring mineral, is important for oral health because it reduces enamel demineralization, inhibits bacterial metabolism and acid production, and promotes enamel remineralization. Fluoride is the cornerstone of protective strategies and is available from many sources, and it is categorized into three major divisions: systemic and topical supplementation through fluoridated drinking water, tablets, or drops; topical administration through toothpastes and rinses, which have already been discussed; and professionally prescribed products (
      • Clark M.B.
      • Slayton R.L.
      Section on Oral Health
      Fluoride use in caries prevention in the primary care setting.
      ). Since the introduction of community water fluoridation, the incidence of dental caries has decreased by 35% (
      • Iheozor-Ejiofor Z.
      • Worthington H.V.
      • Walsh T.
      • O'Malley L.
      • Clarkson J.E.
      • Macey R.
      • Glenny A.
      • et al.
      ) and has been deemed one of the top 10 public health achievements of the 20th century in the United States.
      Systemic fluoride supplementation can lessen the likelihood of dental caries in areas where there is inadequate fluoride in the water. This deficiency is defined as less than 0.7 mg/L (or 0.6 ppm or less), and persons drinking water with inadequate levels of fluoride are at risk of the development of dental caries (
      • Clark M.B.
      • Slayton R.L.
      Section on Oral Health
      Fluoride use in caries prevention in the primary care setting.
      ). The
      U.S. Preventive Services Task Force Independent Expert Panel
      Prevention of dental caries in children from birth through age 5 years: U.S. Preventive services task force recommendation statement.
      has consistently found that fluoride supplementation can promote up to an 81% reduction in caries lesions in primary tooth surfaces in the absence of fluoridated water. It is each provider's responsibility to know the fluoride content in the water sources consumed by their patients and prescribe systemic fluoride accordingly. Public water supplemental fluoride can vary by geographic area, with the northern regions in the United States having higher fluoride levels, up to 1 mg/L, versus 0.7 mg/L in the southern regions. It was once thought that in warmer climates people drink more water and thus do not need all the fluoride delivered in that volume of water. However, the latest data show that most water companies are using the 0.7 mg/L threshold for fluoride in the water (
      • Clark M.B.
      • Slayton R.L.
      Section on Oral Health
      Fluoride use in caries prevention in the primary care setting.
      ). It is important to note that bottled water products contain varying amounts of fluoride and that some of these products do not contain any fluoride. Water from a well also contains varying amounts of fluoride. Two houses next door to each other that both have wells may have water with widely varying fluoride content because of the variability of fluoride in differing rock strata. Home filtration systems utilizing reverse osmosis and distillation remove fluoride from drinking water, which may increase the risk of ECC; however, activated charcoal filters (e.g., Brita and Pur) do not remove fluoride from drinking water (
      • Clark M.B.
      • Slayton R.L.
      Section on Oral Health
      Fluoride use in caries prevention in the primary care setting.
      ).
      When prescribing systemic fluoride supplementation, as provided in tablets or drops, it is important to evaluate fluoride exposure from all sources. The CDC maintains a Web site, “My Water's Fluoride,” that can be a useful tool in determining community water fluoride levels. The local water utility should also have that information. Families with well water should have water tested for fluoride content prior to starting systemic fluoride if this information is not already known. Although it is rare, mild to severe fluorosis can occur with supplementation. Most cases are mild and result in small white streaks on teeth (Figure 3). When mild, fluorosis is a cosmetic issue only. Severe fluorosis, which has a prevalence of less than 1% in the United States, can cause pitting or brown discoloration of the teeth (
      • Moyer V.A.
      on behalf of the US Preventive Services Task Force
      Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
      ). If it is deemed that fluoride supplementation should be initiated when water is deficient, it is recommended that it begin at age 6 months and continue through adolescence (Table). Fluoride sources should be periodically reviewed with the family for changes during well-child visits.
      Figure thumbnail gr3
      Figure 3The white spots from fluorosis can look very similar to the white spot lesions of early childhood caries.
      Used with permission. © 2015 Kowolik. This figure appears in color online at www.jpedhc.org.
      TableRecommended oral fluoride supplement schedule
      AgeFluoride concentration in the community drinking water
      1.0 ppm = 1 mg/L.
      < 0.3 ppm0.3-0.6 ppm> 0.6 ppm
      0-6 monthsNoneNoneNone
      6 months-3 years0.25 mg/day
      1.1 mg sodium fluoride contains 0.5 mg of fluoride ion.
      NoneNone
      3-6 years0.50 mg/day0.25 mg/dayNone
      6-16 years1.0 mg/day0.50 mg/dayNone
      Note. Adapted from the
      Centers for Disease Control and Prevention
      Recommendations for using fluoride to prevent and control dental caries in the United States.
      .
      a 1.0 ppm = 1 mg/L.
      b 1.1 mg sodium fluoride contains 0.5 mg of fluoride ion.
      Although fluoride varnish is perhaps a novel idea for many primary care providers, it is not a new product but is commercially available and simple to apply. The varnish contains a concentrated amount (22,600 ppm) of sodium fluoride and is applied directly on the tooth surface. Despite the high concentration of fluoride, no studies have demonstrated the occurrence of fluorosis with the use of varnish (
      • Moyer V.A.
      on behalf of the US Preventive Services Task Force
      Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
      ). Various brands are available, and the solution can easily be applied to the teeth of infants and young children during routine well-child visits every 3 to 6 months in the first 5 years of life. Although previous recommendations were to apply fluoride varnish only to children at high risk of developing dental caries as recognized by a risk assessment tool, the USPSTF and AAP now concur that all children 5 years or younger with primary teeth can benefit from fluoride varnish, regardless of the presence of fluoride in their drinking water or other risk factors. Studies have shown that using a risk-based approach misses opportunities to provide dental caries prevention to children who could benefit from it (
      • Moyer V.A.
      on behalf of the US Preventive Services Task Force
      Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
      ). In several studies, children with fluoride varnish application had up to a 59% reduction of ECC compared with children who did not receive applications of fluoride varnish (
      • Clark M.B.
      • Slayton R.L.
      Section on Oral Health
      Fluoride use in caries prevention in the primary care setting.
      ). Given the high-risk status of the U.S. population, it is reasonable to apply fluoride varnish to every infant, toddler, and preschooler because the harms of this intervention are negligible. This procedure is best accomplished in the primary care setting. However, a barrier to this practice is that many primary care providers did not receive training on fluoride varnish application during their education program. Fortunately, it is a very simple procedure and can be performed by physicians, physician assistants, advanced practice nurses, registered nurses, licensed practical nurses, and, in some states, medical assistants with adequate training (
      • Moyer V.A.
      on behalf of the US Preventive Services Task Force
      Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
      ).

      Fluoride Varnish Application

      By following a few steps (Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9), fluoride varnish application can easily be integrated into well-child visits. Special equipment is not needed. After the application has been completed, the patient and caregiver should be provided with after-care instructions. Refer to individual product inserts for additional information because specific instructions may vary by brand. In most cases, it is advised to avoid eating sticky foods and drinking hot beverages the day of application.
      Figure thumbnail gr4
      Figure 4Step 1: Organize necessary equipment: disposable gloves (preferably nonlatex); 2″ × 2″ gauze sponges; fluoride varnish (preferably in single-dose containers); a light source (overhead, otoscope, or penlight); a paper towel or disposable bib (optional); and a disposable mouth mirror (optional).
      This figure appears in color online at www.jpedhc.org.
      Figure thumbnail gr5
      Figure 5Step 2: Position the child on an examination table if you are able to maintain safety and the child is cooperative.
      For younger children, use the knee-to-knee position for better control and safety. This figure appears in color online at www.jpedhc.org.
      Figure thumbnail gr6
      Figure 6Step 3: Perform a quick inspection of the oral cavity, noting the presence of tooth eruption/exfoliation, white spots or defects in tooth surfaces, and the general condition of oral structures and hygiene.
      This figure appears in color online at www.jpedhc.org.
      Figure thumbnail gr7
      Figure 7Step 4: Starting at the back of the upper arch, dry most posterior teeth and apply varnish to all tooth surfaces using the brush.
      The varnish will solidify on the tooth surface upon contact with saliva, thereby reducing the risk of incidental ingestion. Move to the next area and repeat the process until all upper teeth have been coated. This figure appears in color online at www.jpedhc.org.
      Figure thumbnail gr8
      Figure 8If a child is not cooperative, it is most important to apply the varnish to all front teeth surfaces along the gum line because these surfaces are the most vulnerable to early childhood caries.
      This figure appears in color online at www.jpedhc.org.
      Figure thumbnail gr9
      Figure 9Step 5: Apply varnish to the lower teeth, starting at the back and moving to the front.
      Care should be taken to keep the tongue off the surfaces of the teeth until the application is complete. This figure appears in color online at www.jpedhc.org.

      Other Considerations

      With adoption of the Affordable Care Act, children will potentially have access to dental care that was never before available to them. Pediatric services including oral health care are among the 10 essential health benefits that must be covered for an insurance company to be certified and allowed to be offered in the federal and state Health Insurance Marketplace (
      • Duderstadt K.G.
      Impact of affordable care act on children's oral health: States hold the key.
      ). Currently there is a shortage of pediatric dentists in the United States, which might interfere with the ability of parents to find appropriate oral health care for their children. In 2011 the Human Resources and Services Administration recommended that primary care providers, including NPs, incorporate oral health care services into primary care practice, which will decrease the gap in preventive dental care services for children younger than 5 years (
      • Duderstadt K.G.
      Impact of affordable care act on children's oral health: States hold the key.
      ).
      It is also important to standardize the process of ordering and storing supplies for varnish application. Packing the gloves, gauze, and varnish in a small zip-lock bag can streamline the application in a well-child visit. Also, developing a checklist in the electronic medical record to help with risk-based education and oral health screening will make the task easier.

      Cost and Reimbursement

      Early preventive dental health care reduces the overall cost of ECC. Preventing the development of ECC will help avoid the need for emergency care and restorative procedures related to ECC. According to the
      American Academy of Pediatric Dentistry
      Policy on early childhood caries (ECC): Classifications, consequences, and preventive strategies. American Academy of Pediatric Dentistry Reference Manual V 36/NO 6.
      , the total cost of treating severe dental caries ranges from $10,000 to $25,000 per child depending on severity of the disease. It is estimated that $40 billion per year is spent on treatment of dental caries; the Medicaid program alone spends between $100 and $400 million to treat dental caries annually (
      American Academy of Pediatric Dentistry
      Policy on early childhood caries (ECC): Classifications, consequences, and preventive strategies. American Academy of Pediatric Dentistry Reference Manual V 36/NO 6.
      ).
      In most states, Medicaid will reimburse providers for the application of fluoride varnish. According to
      • Moyer V.A.
      on behalf of the US Preventive Services Task Force
      Prevention of dental caries in children from birth through age 5 years: US Preventive Services Task Force recommendation statement.
      , state Medicaid reimbursement for fluoride varnish ranges from $9 to $53 per visit. To find out if your state allows reimbursement and to whom reimbursement is allowed, you may access the following Web site: http://www2.aap.org/oralhealth/states/IN.html. Determining if fluoride varnish must be applied during a well-child examination utilizing a preventive care code should be done prior to application and billing (
      • Clark M.B.
      • Slayton R.L.
      Section on Oral Health
      Fluoride use in caries prevention in the primary care setting.
      ). A list of acceptable CPT codes can be found at https://www.medicalhomeportal.org/clinical-practice/screening-and-prevention/oral-health.
      All NPs should be assessing infants and children for white spot lesions, the first sign of ECC, and provide education on oral hygiene, diet, and nutrition to decrease the prevalence of ECC.

      Conclusion

      ECC is an infectious, chronic disease that could be greatly reduced through education and primary prevention strategies. One major obstacle for providing oral health care for children is access to dental care (
      • Crall J.J.
      Development and integration of oral health services for preschool-age children.
      ). It has been suggested that primary care providers could be used to fill this gap, because children are almost 45 times more likely to see a primary medical provider than a dentist within the first 3 years of their lives (
      American Academy of Pediatrics, Section on Pediatric Dentistry and Oral Health
      Preventive oral health intervention for pediatricians.
      ). NPs have been at the forefront of delivering preventive care for patients since the inception of the profession. They therefore are best positioned not only to fill the need gap but to provide the necessary education to promote dental health during the developmental stage when families are establishing oral health routines (
      • Quinonez R.B.
      • Stearns S.C.
      • Talekar B.S.
      • Rozier R.G.
      • Downs S.M.
      Simulating cost-effectiveness of fluoride varnish during well-child visits for Medicaid-enrolled children.
      ). All NPs should be assessing infants and children for white spot lesions, the first sign of ECC, and provide education on oral hygiene, diet, and nutrition to decrease the prevalence of ECC. All infants and children age 5 years or younger need to have fluoride varnish applied at well-child visits upon eruption of their first tooth and continuously every 3 to 6 months at all subsequent well-child visits. NPs need to be leaders in our approach to oral health for all infants and children and make this practice a standard of care.
      We thank Dr. Joan E. Kowolik, Associate Professor at Indiana University School of Dentistry, for providing permission to use her dental photographs, and we thank Malinda Mundy-Burgett, DDS, and Lauren Abbott, LDH, of Grin Dentistry for their invaluable knowledge and support.

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      Biography

      Carol A. Clark, Clinical Assistant Professor, Indiana University School of Nursing, Indianapolis, IN.
      Kathleen A. Kent, Clinical Assistant Professor, Indiana University School of Nursing, Indianapolis, IN.
      Richard D. Jackson, Associate Professor, Indiana University School of Dentistry, Indianapolis, IN.

      Linked Article