1. CHDP Dental Training: Fluoride Varnish
Preparation for this Presentation:
To best prepare for this training, trainer should review the Trainer Guide found on the CHDP Fluoride Varnish Training web home page.
Review all slides and links including videos for background information.
Consider printing power point (PPT) 3-6 slides per page for each participant.
Make sure you are able to show one of the two Fluoride Varnish application videos on Slide #12. Download in advance, if there is no internet access available during the training.
If internet access is available and time permits, open links on slides to show providers a video during the presentation.
There will be a Fluoride Varnish application practicum following the PPT. Be prepared to demonstrate applying the Fluoride Varnish prior to the training, by practicing on yourself or another person. Make sure to have all the Fluoride Varnish materials ready for your demonstration and practice session.
If at the end of the presentation, providers indicate a need for additional training on their evaluation form, local CHDP staff can either:
Contact their local dental or dental hygiene society, or dental school to get a list of volunteers to do a hands on training, OR
Provide contact information for these organizations to give to the providers.
Speaker Tip:
Describe contents of training packet.
The information provided in this training is based on the California CHDP Health Assessment Guidelines, Provider Manual, and the most current AAP oral health policy. This training also references studies and reports from organizations including CDC, California Dental Association, and the Pew Center, among others.
Talking Points:
The CHDP Fluoride Varnish Training provides the knowledge and skills to help you become confident in applying fluoride varnish to young children who are high risk for tooth decay.
This presentation will also explain the reasoning behind providing fluoride varnish in a medical setting.
We encourage you to visit the State CHDP website training page (Link on bottom of this slide) and explore helpful links and references found throughout this presentation.
California Child Health & Disability Prevention (CHDP) Program Statewide Oral Health Subcommittee
June 2013 1

2. Training Objectives
Recognize the importance of providing fluoride varnish to high risk children (0 to 6 years) in the medical office.
Establish a protocol to implement fluoride varnish application in the medical office.
Identify children at risk for dental decay.
Apply fluoride varnish with confidence.
Talking Points:
By the end of this training, you will be able to… (Review slide bullets with providers)
There will be a short evaluation at the end of this training. 1

3. The CHDP Provider’s Role
Fluoride Varnish
The CHDP Provider’s Role
Preparation:
For background information on Fluoride Varnish read this article:
(Fluoride Varnish: an Evidence-Based Approach Research Brief)
Speaker Tip: Present at least one Fluoride Varnish video along with the slides if you have internet access.
Talking Points:
Fluoride re-mineralizes the enamel of teeth and can inhibit the ability of bacteria to produce acid, by blocking bacterial enzymes.
Traditionally fluoride treatments have been provided in the dental office. Due to the high risk of dental decay in our CHDP population and other low-income children, this preventive application should also be provided in the medical setting.
Providers can be reimbursed up to 3 times/year for fluoride varnish applications on children (0 through 5) with Medi-Cal. These applications are in addition to what is provided in a dental office.
Medi-Cal providers now have a responsibility to offer this preventive measure to aid in reducing the incidence of early childhood caries! 1

4. CHDP Providers Prevent Dental Decay
Young children are seen earlier and more frequently by medical providers than by a dentist
Low income young children are at highest risk for dental decay
Medical providers are now placing fluoride varnish to prevent decay
Research shows high
efficacy of fluoride varnish*
Talking Point
Even if a child is taking a systemic fluoride, the use of topical fluorides, including fluoride varnish is still recommended. * 1

5. Fluoride Varnish - Nationwide Effort by Medical Providers
Preparation:
Review Pew Center website.
Talking Points:
We applaud the fact that fluoride varnish has been accepted as a Medicaid benefit throughout most of the nation.
The decision to reimburse for fluoride varnish reflects research showing the efficacy of additional applications to reduce dental decay in high risk children.
Fluoride varnish is a Medi-Cal benefit and should be made available to all children with Medi-Cal age 0 through 5.
Billing will be discussed later in this presentation. 1

6. Fluoride Varnish - Who Needs It?
CHDP children are at high caries risk!*
Other Caries Risk Factors:
Active or Past Tooth Decay
– In parents, siblings, caregivers or child
White spot lesions on teeth
Poor Feeding Habits
Frequent snacking on carbohydrates
Sticky sugary foods
Sweet/acidic drinks
Bottle in bed
Bottle after age 1
Lack of Fluoride in
Drinking water **
Vitamins/Supplements
Toothpaste
No Recent Dental Visit
Within the last year
Poor Homecare
– Lack of daily brushing and flossing
Children with Special Health Care Needs
Preparation:
The following information is provided as background, to prepare you for questions medical staff may ask.
Additional risk factors include:
Active or Past Tooth Decay:
Parents can transmit decay causing bacteria to their child via saliva by sharing eating utensils/straws, or cleaning the pacifier by mouth.
Poor Feeding Habits:
Bacteria live in sticky plaque attached to surfaces of the teeth. Any sugary food like milk, juice, cookies, and crackers feed the bacteria making acid. Acid destroys the tooth.
Sleeping with bottle ~ Baby doesn’t completely swallow all the liquid. Sugary drinks, including milk, can pool around teeth. Anything other than water can cause a problem. Introduce a cup at 6 months and stop the bottle by age one.
Lack of Fluoride:
Whether the community water is fluoridated or not, fluoride varnish is still recommended. (See link at bottom of slide to view local fluoride concentration in drinking water.)
Even if a child is taking a systemic fluoride, the use of topical fluorides including fluoride varnish, is still recommended.
No Recent Dental Visit – A Dental Home should be established by age one.
Poor Homecare – Parent should brush their own teeth, and child’s teeth twice a day.
Children with Special Health Care Needs have many health care problems and dental needs may be overlooked, including:
Inability to cooperate
Lack of motor skills
Lack of access to specialized dental care
Medication side effects, including:
reduced saliva
increased caries risk due to sugar based medication
tissue changes including gum overgrowth, and sensitive, red tissue
The risk factors listed on this slide are found in the AAP Risk Assessment Tool, which can be used by providers when assessing risk for fluoride varnish use on their patients. (Link at bottom of slide.)
Speaker Tips:
Emphasis is on CHDP children needing fluoride varnish.
Review the bullets for additional risk factors, including any preparation details listed above, that are appropriate for your audience.
Talking Points:
Fluoride Varnish - Who needs it? CHDP Children need it. Why? Just being a CHDP child means you are at high risk for decay
Research shows low-income children have an increased risk for caries. Besides Low SES, listed here are other risk factors.
Children with Special Health Care Needs have many health care problems and dental needs may be overlooked! They too need the protection of fluoride varnish.
For a more detailed assessment tool, see AAP Risk Assessment Tool - link on bottom of slide. *
* * 1

7. Fluoride Varnish - Which Teeth Benefit?
No Visible Decay
but high risk
Beginning Decay
white chalky decalcification near gum line
Preventable with fluoride varnish and good home care
Reversible with fluoride varnish and better home care to inhibit progression of caries
Advanced Decay
destroyed enamel
Teeth Without pulp exposure or open lesions
Talking Points:.
These photos represent the various stages in which dental caries can progress:
No Visible Decay Fluoride varnish can prevent decay on healthy teeth in high risk children.
Beginning Decay Applying fluoride varnish on white line decalcification areas can strengthen the enamel and reverse the decay process. White line may remain even though enamel is re-mineralizing at each additional fluoride varnish treatment.
Advanced Decay Once the decay destroys the enamel, you can still apply fluoride varnish over all of the teeth, except on a tooth with pulp exposure (big hole).
Teeth Without… Fluoride varnish is contraindicated when stomatitis is present and should not be applied on large open lesions of the teeth or gums.
Provider should show white/brown/black areas to the parents, encourage better brushing along the gum line and explain the need to reduce fermentable carbohydrate exposures.
Irreversible, however with fluoride varnish decay progression is inhibited
~ Dental treatment needed ASAP ~
Avoid these areas, but apply fluoride varnish to all other teeth in the mouth 1

8. Fluoride Varnish - Facts
A protective resin coating of sodium fluoride
Painted on teeth in ≈ 1 minute
1 application cuts decay risk in half *
Applied up to 5x per year
3x in medical office
2x in dental office
Preparation:
If possible bring a sample of fluoride varnish to display and/or samples to share.
(Check with local dental society or other dental contacts for samples. If they do not have any, contact a dental supply company such as: Darby , Patterson , or Henry Schein )
Or to order by the box, contact: Center For Oral Health  
If you plan on demonstrating during the training, in addition to fluoride varnish, be sure to bring: gauze, gloves and hand disinfectant.
Speaker Tips:
If a question about fluorosis arises, speaker can respond: Risk for fluorosis is very low for fluoride varnish due to it’s adhesion and direct uptake into the tooth enamel – very little is swallowed.
For more information:
Talking Points:
Fluoride varnish is a topical fluoride treatment that prevents new caries from forming and helps reverse early caries by depositing fluoride onto the tooth to make it stronger.
Even if the child has had a fluoride application at the dental office the week before, this does not contraindicate another fluoride varnish application in the medical office.
Application is quick, easy and painless. Some children may cry which only improves visibility and access.
Though extremely rare, fluoride varnish allergic reactions can occur when there is a sensitivity to colophony (resin from pine trees). For this reason fluoride varnish is contraindicated for children with pine nut allergy.
For additional information on fluoride varnish we encourage you to do further research. AAP Oral Health Practice Tools:
For more information: 1

9. Frequency of Application
The optimal interval of application has not been established.*
After the first fluoride varnish treatment, subsequent treatments can be applied every 3-4 months.
Schedule during a well child exam, follow-up visit, or stand-alone appointment.
11:00 am
Fluoride Varnish
appointment
Preparation:
Read “Fluoride Varnish Can Prevent Caries in California's Low income Preschool Children” by Gansky, Ramos-Gomez.
Review two tables regarding fluoride varnish applications in “Pediatric Dental Care: Prevention and Management Protocols Based on Caries Risk Assessment” by Ramos-Gomez, Crystal, Featherstone. (See links on bottom of slide.)
Be familiar with CHDP Periodicity Schedule:
Talking Points:
The 2006 American Dental Association clinical recommendations state that the optimal number of fluoride varnish applications and the optimal intervals, have not yet been established. (CDC 2001a; Scheifle, Studen-Pavlovich, Markovic, 2002; ADA, 2006)
Up through 18 months of age the periodicity interval is 3 months and fluoride varnish applications can coincide with these well child visits.
Over the age of 18 months, the intervals of periodicity increase. Providers should schedule children before their next well child visit to apply fluoride varnish for the most effective caries prevention.
Can be reimbursed by Medi-Cal 3 times in a 12 month period.
* (See Page 4)
(See Table 4, P.754 and Table 5, P.756) 1

10. Fluoride Varnish - Who Can Apply?
Medical Office Setting MD
Trained nurses and assistants under MD Rx*
Community Setting** (School, health fair or government program)
Any trained person
With signed parental permission
Under a doctor’s (or dentist’s) prescription
Following doctor’s (or dentist’s) protocol
 Preparation Tips:
Review and/or print documents at links noted at bottom of slide.
Talking Points:
Because of the high efficacy of fluoride varnish and the widespread frequency of Early Childhood Caries (ECC) in low income children, fluoride varnish is now being applied in alternative sites, including medical offices and community settings.
When the procedure is delegated to them, and follows a protocol established by the attending physician, nurses, physician assistants and other medical personnel, such as medical assistants, are legally permitted to apply fluoride varnish.
As of 2010, a new CA law allows any person trained in application to apply fluoride varnish in a public health setting under a dentist’s or physician’s prescription based on either an individual or a population level (e.g., a blanket prescription for all children attending public health events). * ** 1

11. Fluoride Varnish - Application
Talking Points:
To apply fluoride varnish, read manufacturers’ instructions for specific application directions.
In general, instructions are as follows:
Dry teeth with gauze by section or quadrant
Apply fluoride varnish to all tooth surfaces in that area
Repeat in each section until all teeth have been painted with varnish
Varnish immediately sets in contact with saliva.
Fluoride varnish is available in different flavors, and can be clear, white or yellow.
We will be practicing fluoride varnish application after the PPT. The next videos will give you a sense of what to expect. 1

12. Fluoride Varnish - Instructions
Online Videos and Training Modules
American Academy of Pediatrics Television
Smiles for Life - University of Connecticut
Preparation:
Review these three Fluoride Varnish websites.
Speaker’s Tips:
Be sure to show at least one of the two videos to participants.
Maryland’s Mouths Matter is an oral health training. To view a Fluoride Varnish Module go to Module 4 and click “4.2 Fluoride Varnish” on left side of screen.
Maryland’s Mouths Matter Module 4 1

13. Fluoride Varnish - Parent Information
No water restrictions after application
Avoid crunchy, chewy, and hot foods/ drinks for the rest of the day
Do not brush/floss until the next day
Fluoride Varnish may leave a yellowish coating that can be brushed off the next day
BROCHURE
Preparation:
Read and print copy of brochure, or similar handouts to show and share.
Speaker Tips:
This information is what the provider will share with the parent.
Provider should read specific manufacturer’s post application recommendations.
Talking Points:
This brochure contains key information for families and is available in multiple languages. (Copies can be downloaded from the CHDP Fluoride Varnish Web home page or at the bottom of this slide.)
It is helpful to give this brochure to the parent/caregiver in advance to explain the procedure.
After providing the fluoride varnish be sure to give parents post application instructions. (Use either this brochure or tear-off instructions provided by the manufacturer.)
Drinking or rinsing with water after application does not remove fluoride varnish.
Print copies of Fluoride Varnish - Helping Smiles Stay Strong brochure: English, Spanish, Chinese, Hmong, Korean 1

14. Fluoride Varnish - Billing
Reimbursable 3 times (in a 12 month period) for children age 0 through 5
Fee-for-Service Medi-Cal
- Billing code: D1206
Managed Care Medi-Cal
- Reimbursement varies
- Contact individual plan
FQHC
- Not billable as a separate procedure
Preparation:
Review website on slide.
Speaker Tip:
For non Medi-Cal/CHDP children, providers could make arrangements with the family or simply not charge for this inexpensive treatment. (85 cents to $1.25 per application)
Talking Points:
Fluoride varnish is a Medi-Cal benefit and billed directly to Medi-Cal, NOT CHDP.
Children being seen through Gateway are covered through Fee-for-Service (FFS) Medi-Cal.
The Medi-Cal FFS reimbursement can be up to $18.00 per application.
If bringing a child back for an additional fluoride varnish application (out of CHDP periodicity), FFS medical providers can also bill Medi-Cal for an office visit (99211) as well as the Fluoride Varnish (D1206).
Non Medi-Cal CHDP children also need fluoride varnish, but this is not reimbursable by Medi-Cal (or CHDP).
If you have questions about Managed Care reimbursement, contact the plan.
For Federally Qualified Health Centers (FQHCs), fluoride varnish is not a stand alone encounter. There is no separate reimbursement for fluoride varnish; it should be provided at initial and other follow-up visits. 1

15. Fluoride Varnish – How to Order
Three Ways:
Directly:
Oral Health Solutions
Medical Products Laboratories, Inc
Internet search:
Use search term “fluoride varnish buy”
Dental supply companies:
See link below for Fluoride Varnish
vendor list
Preparation:
Print copies of Fluoride Varnish Vendor list for participants. (Link located at bottom of slide.)
Talking Points:
Least expensive product can be ordered through Oral Health Solutions or Medical Products Laboratories, Inc. directly, in quantities from 32 to 200 packets.
If you choose to purchase through a dental supply company, you will need to set up an account first.
Be aware that there is an expiration date, located on box and on each individual packet.
Once product has expired the consistency may change and packets should be discarded. 1

16. Fluoride Varnish Summary:
Can be provided in medical offices up to 3x in a 12 month period
Billable for Medi-Cal children, ages 0 through 5 years
Fee-for-Service Medi-Cal reimbursement - $18 per application
Managed Care Medi-Cal reimbursement - contact the Plan
Speaker Tip:
Speaker should emphasize bullets with participants.
Talking Points:
This summarizes the main points we want you to remember about Fluoride Varnish.
All CHDP children, age 0 through 5 years, should be regarded as high risk for dental decay and should be considered for fluoride varnish.
Please note, referring a child to a dentist is very important, however, a child will miss 3 treatments of Fluoride Varnish if not provided by a medical office. The effectiveness of fluoride varnish has been found to be greater with more applications.
Fluoride Varnish in Your Practice: www2.aap.org/oralhealth/PracticeTools.html 1

17. Easy and Effective
With just a swipe of fluoride varnish,
I can prevent tooth decay for this little girl!
Applying Fluoride Varnish is one of the easiest and most effective procedures a medical provider can do to help protect the oral health of their young patients!
Speaker Tips:
Read the slide to participants.
Talking Points:
Takes 2 minutes to apply, can cut a child’s risk for decay in half!
Can be delegated to and empowers nursing and medical assistant staff, to be the front line against oral disease.
Can be applied at any time after the oral assessment.
Can prevent a cavity with a swipe of a fluoride varnish brush. 1

18. Together we can stop the epidemic of dental disease!
Working Together
CHDP
Medical Providers
Together we can stop the epidemic of dental disease!
Dental Providers
Preparation:
If participants indicate a need for additional training on their evaluation form, local CHDP staff can either:
Contact the local dental society, hygiene or dental school to get a list of volunteers to give to providers, or
Provide contact information for these organizations to providers.
Speaker Tips:
Be prepared to show participants MD-DDS Referral Form.
At end of PPT presentation, be prepared to demonstrate fluoride varnish application (on a volunteer or tooth model), and then have participants practice on each other. This is an important part of the training.
Talking Points:
This website (link at bottom) has the contact information for the local/county CHDP offices.
Physicians and medical staff are essential partners and your help is needed!
Fluoride Varnish application in the medical office is an important prevention tool, but it doesn’t replace the need for a routine visit with the dentist.
Use the MD-DDS referral form to encourage your patients to make their twice yearly dental appointments (or sooner if a problem is suspected or detected).
This referral form can be found printed in your training packet, or online at the CHDP Dental Training: Fluoride Varnish home page. (See MD-DDS referral form on next reference slide.)
Remember, we can’t have overall health without oral health.
Individuals
Parents/Caregivers
MD - DDS Referral Form:
Local CHDP contact information: 1

19. To return to the beginning of the Fluoride Varnish Training click HERE
References
Fluoride Varnish
General Information
www2.aap.org/oralhealth/PracticeTools.html
#10
National Effort
Effectiveness
Risk Assessment Tool
Who Can Apply
files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/dental_m00o03o09.doc
cda.org/popup/cda-sponsored_legislation_clarifies_who_can_place_topical_fluoride_including_fluoride_varnish
Parent Brochure
Training Modules
Billing Code
MD-DDS Referral Form
Talking Points:
This slide lists the references used in this presentation for your further research.
The website link located at the bottom of this slide lists the local CHDP offices and their contact information. This information is also found on the State CHDP Website under Individuals, Contact a CHDP Program.
To share this training with your staff and colleagues, you can find it online at the State CHDP website training page. Link is located at the bottom of this slide.
To return to the beginning of the Fluoride Varnish Training click HERE
************************************************************
For CHDP Dental and other trainings:
For local CHDP contact information:
Photos and graphics in this training were used by permission or from public domain. 1

20. Fluoride Varnish - Practicum -
Speaker Demonstration
Participant Practice
Preparation:
Bring enough practice materials for all participants:
Sample fluoride varnish
Hand sanitizer
Gauze squares
Gloves
Paper towels
Disinfectant
Speaker Tips:
Demonstrate first on either model, puppet, or participant. (Note: Fluoride Varnish can be removed from a doll/model with disinfectant or hand sanitizer.)
Pair up participants to practice on each other.
After the practicum, instruct participants to complete evaluation form. Collect all forms and thank participants.
Talking Points During Demonstration:
Wrap the gauze around index finger of non-dominant hand.
Dry teeth one section or quadrant at a time, with gauze-covered finger – keeping finger in mouth to retract cheek/lip.
Use brush to apply fluoride varnish to all tooth surfaces in that area, keeping mouth open with gauze covered finger.
Repeat in each section until all teeth have been painted with varnish.
Hint: Try to keep the child’s mouth open during the entire application to prevent the child from tasting the varnish, to keep areas dry, and to speed the application.
California Child Health & Disability Prevention (CHDP) Program Statewide Oral Health Subcommittee
June 2013 1