All About Fluoride: Updated Clinical Report On Caries Prevention In Primary Care

Tooth decay remains one of the most common chronic childhood diseases in the United States, but access to dental care is a challenge for many. Caries disproportionately affects poor, young population groups and children with special health needs.

Good oral health is a necessary part of overall health, and poor oral health adversely affects several chronic conditions. Failure to prevent tooth decay has significant health, educational and financial consequences for individuals and society.

Simple preventive measures at home and in primary care can save healthcare costs.

Pediatricians often see young children and provide advice on diet and oral hygiene. Thus, they are uniquely positioned to participate in the primary prevention of dental caries.

An updated AAP Clinical Report from the Oral Health Section is designed to help pediatricians maximize the use of fluoride to prevent tooth decay while minimizing the risk of enamel fluorosis. It also clears up the advice pediatricians should give regarding fluoride use at home.

The report Fluoride Use in Caries Prevention in the Primary Care Setting is available at and will be published in the December issue of Pediatrics.

Toothpaste, fluoride varnish

The clinical report advises pediatricians in assessing the risk of tooth decay and fluoride exposure in a child in order to make fluoride decisions and provide targeted predictive guidance and education.

The recommendations, unchanged from the 2014 report, include the use of fluoride toothpaste for all children as soon as the first tooth erupts. The amount should be limited to a tiny “smear” or grain of rice up to the age of 3. From the age of 3, a pea-sized amount of fluoride toothpaste is recommended if the child can cough up. Children should spit without rinsing, and the toothbrush should be the last thing to touch teeth at night.

Applying fluoride varnish is now considered the standard of care in primary pediatric care. The United States Preventive Services Task Force (USPSTF) recommends that primary care physicians treat the teeth of all infants and children with fluoride varnish from eruption through the age of 5 years. All children in this age group should have a fluoride varnish at least every six months. Children at higher risk, including those with established tooth decay, should be applied with fluoride varnish every three months (four times a year) in the medical home.

Medicaid will pay doctors in all 50 states to apply fluoride varnish.

The recommendations of USPSTF and Bright Futures are considered the standard of care. The Affordable Care Act requires that all insurance, public and private, cover non-cost-sharing benefits to patients or families.

The report highlights the administrative, billing, and payment information related to the fluoride varnish process. The CPT code for fluoride varnish is 99188 and should be linked to the ICD-10 code Z29.3, Encounter on prophylactic fluoride administration.

Other sources of fluoride

Over-the-counter fluoride mouthwashes are still only recommended for children aged 6 and over who are at high risk of tooth decay.

Community water fluoridation provides topical and systemic exposure to fluoride and helps prevent tooth decay. Fluoridation of water is an effective and safe way to protect the most vulnerable members of the population from tooth decay. Pediatricians are encouraged to advocate public water fluoridation in their communities and states.

Fluoride supplementation should be considered for children 6 months to 16 years old who live in communities where the water is non-fluoridated or who drink non-fluorinated well water.

Silver diamine fluoride

The clinical report calls attention to silver diamine fluoride (SDF), a minimally invasive, low cost, liquid nonsurgical technique for treating carious lesions. SDF can stop cavitated lesions as part of a comprehensive tooth decay management program in the dental office.

Pediatricians see an increasing number of SDF-treated teeth in their practice. You should understand the indications for SDF and recognize the clinical appearance of SDF-treated teeth.

Dr. Clark, a lead author of the clinical report, is a past member of the Executive Committee of the AAP Oral Health Section.

Copyright © 2020 American Academy of Pediatrics

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