Fluoride varnish manual : resources & information

Georgia Oral Health Prevention Program
Fluoride Varnish Manual Resources
&
Information

Table of Contents
1. Introduction and Objectives 2. Why Promote Fluoride Varnish in Georgia 3. Advantages and Benefits of Fluoride Varnish 4. Appropriate use of Fluoride Varnish 5. Application of Fluoride Varnish 6. Considerations
Who may Apply Fluoride Varnish in Georgia 7. Professional Resources
Supporting Evidence Ordering Fluoride Varnish Medicaid/PeachCare/CMO Billing Information Consent Forms, Samples Parental Information on Fluoride Varnish 8. Fluoride Varnish Programs, Implementation Resources 9. Resources from Other States, Agencies and Programs 10. References 11. Samples of Georgia Consent Forms

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1. Introduction and Objectives
Oral health is an essential and integral component of health throughout life. Poor oral health and untreated infections can have a significant impact on the quality of life for school aged children.1 Evidence-based studies indicate oral health prevention is cost-effective and saves children from pain and lost days of school. The National Institutes of Dental and Craniofacial Research and the National Education Association cite research showing that American children miss 52 million hours of school each year due to oral health problems.2 In addition to lost days of school due to dental treatment and pain, dental problems distract children from learning. Preventive dental services reduce costly dental problems. Pediatric Dentistry reported a study documenting a three-year aggregate comparison of Medicaid reimbursement for inpatient emergency department treatment ($6,498) versus preventive treatment ($660) revealed that on average, the cost to manage symptoms related to dental caries on an inpatient basis is approximately 10 times more than to provide dental care for these same patients in a dental office. 3
Dental disease puts our children at-risk for expensive chronic diseases. Studies have shown a link between oral disease and cardiovascular disease, diabetes, respiratory infections, and low birth weight. Tooth decay is five times more common than asthma. 4
The purpose of this manual is to provide information on fluoride varnish use and application in public health oral health programs to medical and dental professionals in the state of Georgia. Electronic hyperlinks to information are provided throughout the document for quick access. Guidance specific to Georgia along with materials and resources that have been developed nationally are presented. This manual was created by Linda L. Koskela RDH, MPH Director, Georgia Oral Health Prevention Program under the direction of Elizabeth C. Lense DDS, MHA Georgia's State Dental Director/ Director, Oral Health Section.
Increasing access to care is a multifaceted effort including public health oral health programs, publicly funded Medicaid and SCHIP programs, private dental professionals, the professional medical community, professional associations and numerous other partners. The Department of Early Care and Learning, Head Start, the Department of Education, the Department of Human Resources Division of Public Health - Office of Birth Outcomes, the School Health Program, and the Infant and Child Health Programs, all play key roles in providing access to oral health care statewide in Georgia.
The statement that "age two is too late" for provision of preventive oral health services to at risk children is widely quoted among public health dental professionals. Oral health assessments during medical visits (well baby checkups) by six months of age and referrals of at risk children to dental providers by age one is recommended by the American Academy of Pediatrics 5. Medical providers have the earliest contact with infants and mothers. This represents an opportunity for early identification, parental education and intervention to prevent dental diseases from developing in young children.
We wish to extend our sincere thanks to states that have publicly shared developed resources and tools that assist providers in all states to increase access to oral health assessments and prevention services targeting young children. Appropriate acknowledgement of resources is provided throughout this manual and noted in the references section. Use of available resources is cost effective and promotes national collaborations to effectively address access to care issues and to support science based initiatives.

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2. Why promote use of fluoride varnish in Georgia
The oral health status of third (3rd) grade children in Georgia was measured by the 2005 Georgia Third Grade Oral Health Survey6. This basic screening survey7 provides a valuable update on oral health status to the information gathered by the 1989 Georgia dental disease prevalence survey8.
Key findings of the 3rd grade survey demonstrate the need for preventive oral health measures targeting at risk children:
1 in 2 (56%) 3rd grade children in Georgia have caries experience. 1 in 4 (27%) 3rd grade children in Georgia have untreated dental decay. 4 in 10 (40%) 3rd grade children in Georgia have dental sealants. 1 in 4 (26%) 3rd grade children in Georgia need either early (22%) or urgent (4%) dental care. Children from high socioeconomic (SES) households are more likely to have good oral health than children
from low SES households. Children from Metropolitan Atlanta are more likely to have good oral health than children from other regions,
except for dental sealants. Children with access to dental insurance are more likely to have good oral health than children without access
to dental insurance. Children who visited a dentist in the last year are more likely to have good oral health than children who had
not visited the dentist in the last year. 1 in 8 (13%) of 3rd grade children in Georgia could not get dental care when needed.
Additionally: All sex, race, and SES groups did not meet the Healthy People 20109 objective (42%) for caries
experience. Children from the Metropolitan Atlanta region are least likely to have caries experience. Children from high SES households are the only income group to meet the Healthy People 2010
objective (21%) for untreated dental decay. By region, only the Metropolitan Atlanta area met the Healthy People 2010 objective (21%) for untreated dental decay. All sex, race, and SES groups did not meet the Healthy People 2010 objective (50%) for dental sealants. Children from Georgia regions defined as small cities are most likely to have dental sealants. None of the regions in Georgia met the Healthy People 2010 objective (50%) for dental sealants. Children from low SES households are more likely to need dental care (34%) than children from high SES households (18%).
The percentage of children with caries experience, untreated dental decay, and dental sealants do not meet Healthy People 2010 objectives regardless of dental insurance status, including publicly funded programs.
The 2006/7 Georgia Head Start Oral Health Survey6 provides information on the oral health status of young children who attend Head Start statewide. This survey gathered data on both nonHispanic and Hispanic Head Start populations. Convenience sampling techniques were used to include sufficient numbers of Hispanic children to provide survey analysis that would be statistically significant and representative of the oral health status of this population group statewide. Overall selection of Head Start centers included in the survey was accomplished through random sampling of all Head Start centers in Georgia. Data analysis was performed by age groups and by ethnicity. Results presented here illustrate the dental disease burden experienced by young children statewide. Documentation provided by these

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surveys demonstrates the need for preventive oral health services for children throughout Georgia, especially young children. The statement that "Age 2 is too late" is proving to be true in Georgia, as well as in other states.
Key Findings (All surveyed NON-HISPANIC children aged between 2 years and 5 years) 2 in 5 (40%) of children in Georgia have early childhood caries (any primary tooth).
1 in 4 (25%) children in Georgia have untreated caries.
1 in 5 (20%) children in Georgia have white spot lesions.
1 in 5 (21%) children in Georgia have early severe childhood caries (anterior/front primary teeth).
1 in 10 (10%) children in Georgia have rampant dental decay.
3 in 10 (29%) children in Georgia require either early (25%) or urgent (4%) dental care.
Key Findings (All surveyed HISPANIC children aged between 2 years and 5 years) 1 in 2 (52%) of children in Georgia have caries experience.
3 in 10 (28%) children in Georgia have untreated caries.
1 in 5 (19%) children in Georgia have white spot lesions.
3 in 10 (28%) children in Georgia have early childhood caries.
1 in 7 (14%) children in Georgia have rampant dental decay.
3 in 10 (30%) children in Georgia require either early (26%) or urgent (4%) dental care.
Key Findings (All surveyed Head Start children aged <3 years) 1 in 6 (17%) children in Georgia have caries experience.
1 in 11 (8%) children in Georgia have untreated caries.
1 in 6 (17%) children in Georgia have white spot lesions.
1 in 6 (17%) children in Georgia have early childhood caries.
1 in 17 (6%) children in Georgia have rampant dental decay.
1 in 11 (8%) children in Georgia require early dental care.
The dental disease rates for young children in Georgia clearly show that the use of fluoride varnish will benefit at risk children. White spot lesions are an indicator of risk for more serious dental problems. Rates of 17-20% of surveyed children with white spot lesions provide an opportunity for early intervention through application of fluoride varnish to arrest the developing dental caries, and either stop or slow the progression towards early childhood caries or rampant decay. Wide spread use of fluoride varnish in public health programs, and applications by other medical and dental professionals will provide long term prevention benefits for children at risk for poor oral health. Subsequent 3rd grade and Head Start Surveys will provide data measuring the impact of statewide fluoride varnish and prevention programs.
It is expected that Head Start children receiving the benefits of fluoride varnish will experience lower rates of dental disease by the time they reach the 3rd grade, than those documented by the 2005 basic screening survey. Continuous improvement of the oral health status of children statewide is the overall goal of the Georgia Oral Health Prevention Program.

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3. Advantages and Benefits of Fluoride Varnish
The Centers for Disease Control and Prevention's (CDC) Morbidity and Mortality Weekly Report publication on Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States: August 17, 2001 provides scientific support for use of fluoride varnish for appropriate populations. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm. Please refer to this publication for references where indicated by an asterisk (*).
Widespread use of fluoride has been a major factor in the decline in the prevalence and severity of dental caries (i.e., tooth decay) in the United States and other economically developed countries. When used appropriately, fluoride is both safe and effective in preventing and controlling dental caries. High-concentration fluoride varnish is painted directly onto the teeth. Fluoride varnish is not intended to adhere permanently; this method holds a high concentration of fluoride in a small amount of material in close contact with the teeth for many hours. Fluoride varnish has practical advantages (e.g., ease of application, a non-offensive taste, and use of smaller amounts of fluoride than required for gel applications). Such varnishes are available as sodium fluoride (2.26% [2,600 ppm] fluoride) or difluorsilane (0.1% [1,000 ppm] fluoride) preparations.
Fluoride varnish has been widely used in Canada and Europe since the 1970s to prevent dental caries*. FDA's Center for Devices and Radiological Health has cleared fluoride varnish as a medical device to be used as a cavity liner (i.e., to provide fluoride at the junction of filling material and tooth) and root desensitizer (i.e., to reduce sensitivity to temperature and touch that sometimes occurs on root surfaces exposed by receding gingiva)*; FDA has not yet approved this product as an anticaries agent. Caries prevention is regarded as a drug claim, and companies would be required to submit appropriate clinical trial evidence for review before this product could be marketed as an anticaries agent. However, a prescribing practitioner can use fluoride varnish for caries prevention as an "off-label" use, based on professional judgment*.
Studies conducted in Canada* and Europe* have reported that fluoride varnish is efficacious in preventing dental caries in children. Applied semiannually, this modality is as effective as professionally applied fluoride gel*. Some researchers advocate application of fluoride varnish as many as four times per year to achieve maximum effect, but the evidence of benefits from more than two applications per year remains inconclusive*. Other studies have reported that three applications in 1 week, once per year, might be more effective than the more conventional semiannual regimen*.
European studies have reported that fluoride varnish prevents decalcification (i.e., an early stage of dental caries) beneath orthodontic bands* and slows the progression of existing enamel lesions*. Studies examining the effectiveness of varnish in controlling early childhood caries are being conducted in the United States. Research on fluoride varnish (e.g., optimal fluoride concentration, the most effective application protocols, and its efficacy relative to other fluoride modalities) is likely to continue in both Europe and North America.
No published evidence indicates that professionally applied fluoride varnish is a risk factor for enamel fluorosis, even among children aged <6 years. Proper application technique reduces the possibility that a patient will swallow varnish during its application and limits the total amount of fluoride swallowed as the varnish wears off the teeth over several hours.
4. Appropriate use of Fluoride Varnish
Indications for use of fluoride supplements, rinses and topical treatments include lack of optimal fluoride in the drinking water, populations identified as having high risk for dental disease and individuals with a history of dental caries experience. Additionally, topical fluorides are often used as desensitizing

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agents for adult dental patients with exposed root surfaces. Dental practitioners may prescribe fluoride varnish for children and adults based upon screening or examination results, known risk factors and professional judgment. Physicians and registered nurses may conduct oral assessments and family interviews to determine appropriate prescription of the fluoride varnish or dietary supplements for young children. Caution in prescribing dietary supplements is recommended to avoid fluorosis of the dental enamel causing a mottled (spotted) appearance of developing teeth. Dosage of supplements is based upon the amount of fluoride in drinking water (from My Waters' Fluoride11) that the child may consume, and the age and weight of the child. The following tables reproduced from the CDC publication Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States: August 17, 2001 provide guidance in determining the appropriate prescription dose, and provide definitions of the populations that may benefit from use of fluoride varnish.

Populations believed to be at increased risk for dental caries are those with low socioeconomic status (SES) or low levels of parental education, those who do not seek regular dental care, and those without dental insurance or access to dental services. Persons can be at high risk for dental caries even if they do not have these recognized factors. Individual factors that

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possibly increase risk include active dental caries; a history of high caries in older siblings or caregivers; root surfaces exposed by gingival recession; high levels of infection with cariogenic bacteria; impaired ability to maintain oral hygiene; malformed enamel or dentin; reduced salivary flow because of medications, radiation treatment, or disease; low salivary buffering capacity (i.e., decreased ability of saliva to neutralize acids); and the wearing of space maintainers, orthodontic appliances, or dental prostheses. Risk can increase if any of these factors are combined with dietary practices conducive to dental caries (i.e., frequent consumption of refined carbohydrates). Risk decreases with adequate exposure to fluoride.

A conference paper provided by the Medical College of Georgia, School of Dentistry titled

Evidence-based Use of Fluoride in Contemporary Pediatric Dental Practice by Steven M. Adair,

DDS, MS, provides information on multiple methods of fluoride delivery.

http://www.first5oralhealth.org/downloads/0/1631/Adair-28-2.pdf

Table 2. Summary of the Author's Recommendations for the Use of Fluoride Regimens in Contemporary Pediatric Dental Practice*

Fluoride regimen Dietary supplements
Dentifrices
Mouthrinses Self-applied gels/pastes (5000 ppm F)
Professionally applied gel/foam (12,300 ppm F)

Recommendations
Assay patient's primary source of drinking water; consider other sources of fluoride intake Consider delaying supplementation until after eruption of permanent first molars Ensure that parents understand risks/benefits of supplementation Instruct patient to chew/swish supplement prior to swallowing Prescribe no more than 120 mg F No benefit to prenatal administration Use in children <2 yrs old should be based on caries risk assessment Tooth-brushing for young child should be done by adult; brushing by older child should be supervised by adult Use pea-sized dab of dentifrice in children with immature swallowing reflexes; older children can use larger amounts Brush with fluoride toothpaste twice daily Reserve for use in children with moderate/high caries risk Reserve for use in children who have mastered swallowing reflex Recommend alcohol-free preparations Reserve for patients in fluoride-deficient communities who are at increased risk for caries Application should be done by adult for young child, and supervised by adult for older child Application period should be 4 minutes Allow patient to expectorate freely after application; postpone eating/drinking for 30 minutes Use with caution in children who have not mastered swallowing reflex Monitor effectiveness; terminate regimen when feasible Application frequency based on caries risk assessment Follow a pumice prophylaxis with fluoride application Use minimum amount of gel/foam necessary to cover teeth Seat patient upright, use suction to reduce swallowing of product Apply for 4 minutes Allow patient to expectorate freely after application; postpone eating/drinking for 30 minutes

Fluoride varnish

Use after pumice prophylaxis as noted for gel/foam application

(22,600 ppm F)

Use in alternative restorative technique to arrest lesions in

young, pre-cooperative patients

Have patient refrain from eating/drinking for 30 minutes after

application

Have patient postpone brushing teeth until following morning

*Table assumes that the baseline recommendation for all patients is twice daily use of a fluoridated dentifrice coupled with once- or

twice-yearly professional application of fluoride gel/foam/varnish. Use of all regimens except fluoride dentifrice should be based on a

caries risk assessment.

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The University of Iowa, College of Dentistry provides the following indications for fluoride varnish application http://www.pediatriceducation.org/2007/03/26#a205:
Ages 0-36 months, well-child visit, and no application of varnish within the past 6 months Cavities, previous cavities, plaque, stained grooves, Medicaid or no insurance, or new teeth erupting Teeth present in the mouth No contraindications to application of varnish
My Water's Fluoride web site http://apps.nccd.cdc.gov/MWF/Index.asp allows consumers in currently participating states to learn the fluoridation status of their water system. The best source of information on fluoride levels in your water system is your local water utility. All water utilities must provide their consumers with a Consumer Confidence Report (CCR) that provides information on a system's water quality, including its fluoridation level. http://www.epa.gov/safewater/ccr/whereyoulive.html Links on this web page are provided by water suppliers who have chosen to link its CCR to EPA's web site, although it is not required.
The Georgia Rural Water Association http://www.grwa.org/ or 770.358.0221 may also help you to identify the fluoride level of your drinking water. Funding is provided by the Georgia Division of Public, Oral Health Section for monitoring of appropriate levels of fluoride provided through water fluoridation. Reported results are also provided on the My Water's Fluoride web site.
5. Application of Fluoride Varnish
Smiles for Ohio Fluoride Varnish Video: http://www.mchoralhealth.org/materials/multiples/smilesforohio/FV%20RefGuide.pdf
Fluoride varnish is quickly and easily applied, without trays or suction. This is especially helpful for infants, toddlers and developmentally disabled individuals. Fluoride varnish is a mostly tasteless liquid with a slightly thickened consistency that is applied with a very small brush applicator. The child's teeth should be as dry as is possible and should not be surrounded by a pool of saliva. Wiping the teeth with gauze is helpful. Apply a thin layer of varnish to all surfaces of the teeth, avoiding use of excess amounts. The varnish will harden immediately once it comes into contact with saliva. Advise the parent that the child's teeth may become discolored temporarily as some fluoride varnish products have a yellowish tinge (from Nevada's Fluoride Varnish Manual). The varnish may be gently brushed off the next day. Some benefits in preventing tooth decay are provided with even one single application12. Repeating the varnish application every three to six months over a two year time period provides the best results.
Use of fluoride varnishes in community-based settings is a developing Best Practice nationally. Local level programs and state dental directors have pushed the demand for information and scientific evidence supporting the use of fluoride varnish in public health programs for at risk populations 13, 14.
6. Considerations
Who may Apply Fluoride Varnish in Georgia
Georgia laws, rules or regulations provide guidance on licensure for dental and medical professionals who may apply fluoride varnish or other topical fluoride treatments. (These references are listed next in the next section, under Professional Resources).
Georgia licensed dentists, dental hygienists, and dental assistants trained in expanded duty functions may apply topical fluoride treatments. Rules on supervision of auxiliaries should be followed with all provision of services.

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Physicians and Registered Nurses who are licensed in Georgia may also perform oral health screening/assessment and apply fluoride varnish. The Georgia Medicaid and PeachCare programs do not have a billing code for fluoride varnish provided by medical professionals. The American Academy of Pediatric Dentistry recommends oral health assessments/screenings during medical visits (well baby check ups), and referral of children identified as being at risk for poor oral health by one year of age to establish a dental home. Early access to preventive services has demonstrated a positive effect on the oral health status of children.
Georgia's public health oral health programs provide access to prevention services through school based programs. Elementary schools and other programs centered on young children are targeted for public health prevention services. School programs with at least 50% of the children eligible for the Free and Reduced Lunch Program or other government sponsored food programs are eligible to participate. Provision of dental screenings, fluoride varnish, child and parent prevention education, and other prevention services through Head Start and early elementary school grades assures access to early preventive care. http://health.state.ga.us/programs/oral/index.asp
7. Professional Resources
i. Composite State Board of Medical Examiners Laws by Medical Specialty: http://medicalboard.georgia.gov/00/channel_modifieddate/0,2096,26729866_28523622,00.ht ml
ii. Georgia Board of Dentistry Professional Licensure http://sos.georgia.gov/plb/dentistry/ and Rules: http://sos.georgia.gov/acrobat/PLB/Rules/chapt150.pdf
iii. Georgia Dental Association http://www.gadental.org/
iv. Georgia Registered Nurses Practice Act http://sos.georgia.gov/acrobat/PLB/laws/38_RN_43-26.pdf
v. The Role of the Pediatrician in the Oral Health of Children: A National Survey PEDIATRICS Vol. 106 No. 6 December 2000, p. e84 http://pediatrics.aappublications.org/cgi/content/full/106/6/e84
vi. Screening Examinations (or assessment) http://rules.sos.state.ga.us/docs/290/5/31/04.PDF
Supporting Evidence
vii. American Academy of Pediatrics - Guideline on Fluoride Therapy http://www.aapd.org/media/Policies_Guidelines/G_FluorideTherapy.pdf
viii. Change in caries prevalence after implementation of a fluoride varnish program http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=15180078& dopt=AbstractPlus This web site has links to studies conducted in Europe over several years.
ix. Fluoride Varnish Efficacy in Preventing Early Childhood Caries http://jdr.iadrjournals.org/cgi/content/full/85/2/172
x. Fluoride Varnish: an Evidence-Based Approach Research Brief http://www.astdd.org/docs/Sept2007FINALFlvarnishpaper.pdf
xi. Fluoride Varnishes, A Review of Their Clinical Use, Cariostatic Mechanism, Efficacy and Safety: http://jada.ada.org/cgi/content/full/131/5/589

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xii. Fluoride Varnish Treatment for Reducing Caries: A Brief Review of the Literature: http://www.contemporaryoralhygieneonline.com/issues/articles/2006-09_06.asp
xiii. Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm
Ordering Fluoride Varnish Products (5% NaF in a natural colophonium resin)
i. CavityShield: http://www.omniipharma.com/cavityshield.asp 1-800-445-3386 (unit- dose package)
ii. Duraflor: http://www.medicom.com/faq.ch2 1-800-435-9267 (unit-dose package)
iii. Duraphat: http://www.colgateprofessional.com/app/cop/jsp/products/productHome.jsp?prodcode=01 1400100 1-800-225-3756 (multi-use tube)
iv. Vanish Fluoride Varnish: http://www.omniipharma.com/vanish.asp (unit-dose package)
v. VarnishAmericaTM: http://www.medicalproductslaboratories.com/products/varnishamerica/varnishamerica.html (unit-dose package)
Medicaid/PeachCare/CMO Billing Information
i. Amerigroup Corporation, Provider Site https://www.amerigroupcorp.com/providers/ProviderPortalWeb/publicpages/ga/
ii. Avesis Third Party Administrators, Inc. has partnered with Peach State Health Plan to manage dental services for Medicaid Members and PeachCare for Kids. http://www.avesis.com/ga_medicaid_dental.html
iii. Delta Dental National Processing Policies http://www.deltadentalnj.com/dentists/downloads/CDT2007changes.pdf
iv. Doral is the one national dental benefits management company that focuses exclusively on government programs. http://www.doralusa.com/Providers/Providers.aspx
v. Georgia Medicaid and PeachCare for Kids: ACS EDI Gateway, Inc. provides HIPAAmandated electronic transaction, code sets and opportunities for providers to submit through an approved claims billing system or using the proprietary WINASAP application. http://www.acs-gcro.com/Medicaid_Accounts/Georgia_Medicaid/georgia_medicaid.htm
vi. WellCare operations in Georgia serve individuals and families who are eligible for Medicaid and PeachCare for Kids. http://georgia.wellcare.com/
Consent Forms, Samples
i. Georgia: samples of consent forms developed by district oral health programs are provided on pages 16-19 of this manual.
ii. North Carolina: http://www.communityhealth.dhhs.state.nc.us/dental/IMB_resources/7_Consent_Form_Engli sh.pdf

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iii. United South and Eastern Tribes Dental Support Center http://www.usetinc.org/images/images_sub/114/FLUORIDE%20VARNISH%20CONSENT %20FORM.doc
iv. University of Massachusetts Memorial Medical Center (FLV and Sealants permission): http://ocp-map.org/PDFs/Programs/DTS/FluorideandSealantPermissionSlip.pdf
Parental Information on Fluoride Varnish
i. California - First Smiles Resources: http://www.first5oralhealth.org/page.asp?page_id=297 Parents Corner: http://www.first5oralhealth.org/page.asp?page_id=292
ii. Childsmile dental health promotion programs in Scotland http://www.childsmile.org/index.aspx?o=1108 helpful information on child oral health behaviors such as drinking from a cup.
iii. Fast Facts sheet for parents: http://www.usetinc.org/images/images_sub/114/Fluoride%20Varnish%20DFF.doc
iv. Kansas: a one page printable Fluoride Varnish Fact Sheet for parents. http://kcsos.kern.org/kccdhn/stories/storyReader$13
v. Saskatchewan Health: a one page printable explanation for parents on fluoride varnish application, step by step. http://www.health.gov.sk.ca/fluoride-varnish
8. Fluoride Varnish Programs, Implementation Resources
i. Access to Baby and Child Dentistry (ABCD) Program ABCD focuses on preventive and restorative dental care for Medicaid-eligible children from birth to age six, with emphasis on enrollment by age one. http://www.abcd-dental.org/index.html
ii. Effect on participation rates of addition of a fluoride varnish component to existing school based dental screening and sealant programs (presented to alert the reader to potential challenges): http://apha.confex.com/apha/132am/techprogram/paper_84360.htm
iii. Fluoride Varnish Training for Physicians using the Into the Mouths of Babes 1-1/2 hour AMA approved CME session https://www.ncafp.com/imb/training.html
iv. Iowa Bureau of Oral Health - Fluoride Varnish Protocol 2 pages http://www.idph.state.ia.us/hpcdp/common/pdf/oral_health/fluoride_protocol.pdf
v. North Carolina: Into the Mouths of Babes http://www.communityhealth.dhhs.state.nc.us/dental/Into_the_Mouths_of_Babes.htm
vi. Oral Health Tutorial designed for non-dental professionals who work with infants, toddlers, preschoolers, children and adults with disabilities: http://www.oralhealthtutorial.org/
vii. Oral Health Provider Training - Healthy Teeth for Mom & Me See section 5 link for 8 page Fluoride Varnish guide http://dhfs.wisconsin.gov/medicaid5/trainings/oral_health_training/index.htm
viii. Whatcom County, Washington Oral Health Coalition - Pediatric Oral Health Guide for the Primary Care Physician http://www.happyteeth.org/media/pdf/primarycare.pdf
see page 2 of parents' brochure available in other languages http://www.happyteeth.org/advocacy/10_simple_ways.htm

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9. Resources from Other States, Agencies and Programs
The American Academy of Pediatrics (AAPD) has oral-care tips for professionals, parents and children. http://www.aap.org/healthtopics/oralhealth.cfm
American Academy of Pediatric Dentistry (AAPD) http://www.aapd.org
i. Oral Health Risk Assessment Training for Pediatricians and Other Child Health Professionals.http://www.aap.org/commpeds/dochs/oralhealth/screening.cfm
Association of State and Territorial Dental Directors www.astdd.org i. Fluoride Varnish: An Evidence-Based Approach Research Brief http://www.astdd.org/docs/FluorideVarnishPaperASTDDSept2007.pdf ii. Fluoridation and Fluorides http://www.astdd.org/index.php?template=fluoridation.html
iii. This web page provides links to each state's oral health program web site http://new.astdd.org/index.php?template=sprogram.php&tier1=State%20Programs
Arizona: Tuba City Fluoride Varnish Program http://www.aap.org/nach/Holve.pdf
California Children and Families Commission: First Smiles http://www.first5oralhealth.org/page.asp?page_id=429
Centers for Disease Control, Oral Health Resources Fact Sheets and FAQs http://www.cdc.gov/OralHealth/factsheets/index.htm
Colgate World of Care http://www.colgate.com/app/Colgate/US/OC/Information/OralHealthAtAnyAge.cvsp
With support from the W.K. Kellogg Foundation, the Economic and Social Research Institute (ESRI) has examined community-based activities across the country intended to improve the oral health of vulnerable populations. http://www.wkkf.org/oralhealth/InteriorPage.aspx?PageID=4&LanguageID=0
George Town University: Bright Futures publications http://brightfutures.aap.org/web/
i. Encounter forms for us in assessments for young children http://www.brightfutures.org/encounter/instructions/instruct_prof.htm
Head Start Bulletin: Head Start and Partners Forum on Oral Health: Paper # 2: Oral Health Assessment and Dental Prevention http://www.headstartinfo.org/publications/hsbulletin71/hsb71_07.htm
Illinois: Bright Smiles from Birth http://www.illinoisaap.org/oralhealth.htm
Iowa: http://www.astdd.org/statepractices/pdf/SUM18002IAfluoridevarnish.pdf
Kansas: Fluoride Varnish Fact Sheet and many helpful links to additional resources http://kcsos.kern.org/kccdhn/stories/storyReader$13
Minnesota: University of Minnesota Fluoride Varnish Course http://www.meded.umn.edu/apps/pediatrics/FluorideVarnish/index.cfmhttp:/
Missouri: K-12 Oral Health Education Curriculum http://www.dhss.mo.gov/oralhealth/
National Association of Pediatric Nurse Practitioners (NAPNAP): http://www.napnap.org/Docs/303.pdf

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National Head Start Oral Health Resource Center (NHSOHRC) http://www.mchoralhealth.org/HeadStart/materials/action.lasso?-database=Biblio&layout=Web&-response=results.lasso&-MaxRecords=all&-DoScript=NHSOHRC_varnish&search
National Maternal and Child Oral Health Resource Center (OHRC) http://www.mchoralhealth.org/
Nevada: Fluoride Varnish Manual http://health2k.state.nv.us/oral/FVManual.pdf
North Carolina: http://www.communityhealth.dhhs.state.nc.us/dental/Into_the_Mouths_of_Babes.htm
i. University of North Carolina, School of Public Health: Presentation at the National Oral Health Conference 2005 http://www.nationaloralhealthconference.com/docs/presentations/2005/0504/recentadvancesi nthefluoridelegacy.PDF
Ohio: Smiles for Ohio Fluoride Varnish Program for Primary Care Providers http://www.mchoralhealth.org/materials/multiples/smilesforohio/ Please note that some files linked to this web page are very large, requiring significant download time.
Pediatric Digital Library and Learning Collaboration: Fluoride Varnish what is it? http://www.pediatriceducation.org/2007/03/26#a205
Rhode Island Department of Health, Oral Health: http://www.health.ri.gov/disease/primarycare/oralhealth/index.php
i. Information sheets on use of mouth guards for parents http://www.health.ri.gov/disease/primarycare/oralhealth/prevention-mouthguards.php
South Dakota: Has a wealth of information for parents; several oral health sites for parents http://doh.sd.gov/OralHealth/default.aspx http://doh.sd.gov/OralHealth/Parents.aspx http://doh.sd.gov/OralHealth/PDF/Overview.pdf
Tennessee: Early Childhood Caries Prevention, A Fluoride Varnish Program for Public Health Nurses http://health.state.tn.us/oralhealth/pdf/Cavity_Free.pdf
United South and Eastern Tribes Incorporated: Incorporated in 1969, United Southeastern Tribes operated first out of Emory University in Atlanta, Georgia. The purpose of the Dental Support Center is to improve access to quality clinical and preventive services. http://www.usetinc.org/defaultpage.cfm?ID=39
United States Department of Health and Human Services Oral Health in America: A Report of the Surgeon General http://www.surgeongeneral.gov/library/oralhealth/
Virginia: Bright Smiles for Babies http://www.vahealth.org/teeth/BrightSmilesBabies.pps
Washington: State Dental Sealant and Fluoride Varnish Program Guidelines http://www.doh.wa.gov/cfh/Oral_Health/Documents/2002_sealant_varnish_manual.pdf
i. Whatcom County Oral Health Coalition http://www.happyteeth.org/about/coalition_publications.htm
Wisconsin: Fluoride Vanish Application Program for Children Agency Protocol http://dhfs.wisconsin.gov/health/Oral_Health/pdf_files/varnishpolicyprocr42505.pdf

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10. References
1. U.S. Department of Health and Human Services, Oral Health in America: A Report of the Surgeon General. Rockville, MD: HHS, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2000. http://www.nidr.nih.gov/sgr/execsumm.htm#challenge
2. National Institutes of Dental and Craniofacial Research (NIDCR): Gift HC, Reisine ST, Larach DC. The social impact of dental problems and visits, Am J Public Health 1992; 82(12): 1663-8. http://drc.nidcr.nih.gov/report/17_1.htm
3. Pettinato Erika, Webb Michael, Seale N. Sue. "A comparison of Medicaid reimbursement for non-definitive pediatric dental treatment in the emergency room versus periodic preventive care". Pediatric Dentistry 2000: 22(6), pp.463-468 http://lib.bioinfo.pl/pmid:11132504
4. Department of Health and Human Services Centers for Disease Control and Prevention Preventing Chronic Disease: Investing Wisely in Health - Preventing Dental Caries, January 2006 http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/pdf/oh.pdf
5. Oral Health Risk Assessment Timing and Establishment of the Dental Home PEDIATRICS Vol. 111 No. 5 May 2003, pp. 1113-1116 http://www.aap.org/healthtopics/oralhealth.cfm
6. Falb M, Kanny D, Duval T, Koskela L. Oral Health of Georgia's Children: Results from the 2005 Georgia Third Grade Oral Health Survey. Georgia Department of Human Resources, Division of Public Health, April 2006.
7. Association of State and Territorial Dental Directors publication Basic Screening Surveys: An Approach to Monitoring Community Oral Health http://astdd.org/index.php?template=surveybss.html, manual: http://www.astdd.org/docs/BSS_Manual_9-25-03.pdf
8. Georgia Dental Association Action: Georgia Dental Disease Prevalence Survey: Alderman, E. J., White, Shelia, Johnson, W.T. April 1994, 17-19.
9. U.S. Department of Health and Human Services: Healthy People 2010, Chapter 21 Oral Health Objectives http://www.healthypeople.gov/Document/HTML/Volume2/21Oral.htm
10. Levin E, Kanny D., Duval, T., Koskela, L. Status of Oral Health in Georgia: Summary of Oral Health Data Collected in Georgia. Georgia Department of Human Resources, Division of Public Health, October 2007.
11. National Center for Chronic Disease Prevention and Health Promotion, Oral Health Data Systems, My Water's Fluoride http://apps.nccd.cdc.gov/mwf/
12. Fluoride Varnish Efficacy in Preventing Early Childhood Caries J Dent Res 85(2):172-176, 2006 http://jdr.iadrjournals.org/cgi/content/abstract/85/2/172
13. Fluoride Varnish: an Evidence-Based Approach Research Brief Association of State and Territorial Dental Directors Fluorides Committee http://www.astdd.org/docs/Sept2007FINALFlvarnishpaper.pdf
14. CDC Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR August 17, 2001a; 50(RR14): 1-42. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm
For more information and resources about programs to address oral health in Georgia, please visit http://health.state.ga.us/programs/oral/ or contact:
Elizabeth C. Lense DDS, MHA Director, Oral Health Section 404-657-2571 eclense@dhr.state.ga.us or Linda L. Koskela RDH, MPH Director, GA Oral Health Prevention Program, (404)-463-2449 llkoskela@dhr.state.ga.us 11th Floor, 2 Peachtree Street NW, Atlanta, GA 30303-3142
Suggested citation: Lense E., Koskela L. Georgia Oral Health Prevention Program Fluoride Varnish Manual 2007 Georgia Department of Human Resources, Division of Public Health, January 2008. Publication Number: DPH08.168HW.

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11. Samples of Georgia Consent Forms
These forms are provided as templates or samples for provider use or to assist creation of forms that more closely fit their needs. Samples selected are representative of those submitted, and of formats used statewide. Thank you, to all Georgia district dental programs who have shared developed forms.

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North Georgia Health District INFORMED CONSENT FLUORIDE VARNISH APPLICATION

Benefit: Fluoride varnish is an easy, effective, and safe way to help protect your child's teeth and prevent cavities. The varnish is painted on your child's teeth with a disposable applicator.
Risk: Fluoride varnishes have been used for many years. Fluoride varnish is not recommended for children with bronchial asthma or for children with a history of allergy to wood resins or rosins.

Call (706) 281-2206 for an appointment and bring this signed permission form with your child.

Male

Child's Name: _________________________

(First) (M.I.)

(Last)

Female Date of Birth_____/_____/____ Month Day Year

Parent's Name:___________________________ Home Phone #____________________ (Area Code and Number)

Address:_______________________________ Work Phone #____________________ (Area Code and Number)

City:______________ State:_______ Zip Code:______

Does your child have Medicaid? Yes__ No__ or Peachcare? Yes__ No__ Please list number _____________________

Health History 1. Has your child had any of the following: (Check "Yes" or "No")

Yes No

Yes No

Asthma/Breathing Problem ___ ___ Blood transfusions

___ ___

Rheumatic Fever/Scarlet Fever ___ ___ Bleeding problems/ Hemophilia ___ ___

Heart valve replacement

___ ___ Seizures or Convulsions/Epilepsy ___ ___

Heart murmur

___ ___ Hepatitis B

___ ___

Heart defects

___ ___ AIDS/HIV

___ ___

Abnormal blood pressure

___ ___ Diabetes

___ ___

Implants

___ ___ TB

___ ___

Kidney problems

___ ___ Cancer

___ ___

Liver problems

___ ___ Allergy to wood rosins/resins ___ ___

Allergy to latex

___ ___

2. Does your child have any other allergies? Yes ____ No____. If yes, please list allergies: __________ _____________________________________________________________________________________.

3. Is your child taking any medications? Yes___ No___ If yes, please list medications: _____________________________________________________________________________________.

4. Is there anything else we should know about the health of your child?__________________________.

Consent: I give permission for an examination by a licensed dental professional to determine the need for fluoride varnish and the application of the fluoride varnish if recommended.

Signature of Parent or Legal Guardian______________________________________Date:_____________

**************************************************************************************

For office use only:

R Y G S V H

Chart #_________

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Beneficio:

Distrito de Salud del Norte de Georgia (North Georgia Health District)
PERMISO INFORMADO- APLICACIN DE CAPA DE FLUORURO
La capa de fluoruro es una forma fcil, efectiva y segura de ayudar a proteger los dientes de su hijo y prevenir caries. Se coloca una capa de barniz a los dientes de su hijo con un aplicador desechable.

Riesgo:

Los barnices de fluoruro han sido usados por muchos aos. No se recomienda el barniz de fluoruro para nios con asma bronquial o para nios con historia de alergia a resinas de madera.

Llame al (706) 281-2206 para una cita y enve este permiso firmado con su hijo.

Nombre del Nio __________________________ Nombre (s) Apellido

Nio Nia

Fecha de nacimiento _____/____/____ mes da ao

Nombre de los Padres: ______________________________ Tel. Casa _______________________________

Direccin: ____________________________________

Tel. Trabajo

Ciudad ___________________ Estado _____________________ Cdigo Postal ____________________

Su hijo tiene Medicaid? S____ No_____ o Peachcare? S____ No_____ Por favor anote el nmero __________

Historia de Salud

1. Su nio ha sufrido de cualquiera de lo siguiente: (marque S o No)

S No

Asma/Problemas para respirar

____ ____ Transfusiones de Sangre

Fiebre Reumtica/Fiebre Escarlatina

____ ____ Problemas de Sangrado/Hemofilia

Reemplazo de vlvula de corazn

____ ____ Convulsiones/Epilepsia

Murmullo del corazn

____ ____ Hepatitis B

Defectos del corazn

____ ____ SIDA/VIH

Presin sangunea anormal

____ ____ Diabetes

Implantes

____ ____ TB

Problemas del rin

____ ____ Cncer

Problemas del hgado

____ ____ Alergia a resinas de madera

Alergia a ltex

S ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

No ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

2. Su hijo tiene otras alergias? S ____. Si las tiene, por favor antelas: ______________________________ ______________________________________________________________________________________________ 3. Su hijo est tomando algn medicamento? S___ No ___ . Si los est tomando, anote cules: ______________________________________________________________________________________________ 4. Hay algo ms que debamos saber acerca de la salud de su hijo? ____________________________

Permiso: Doy permiso para que un profesional dental con licencia examine a mi hijo y que determine si es necesario un barniz de fluoruro y que aplique el barniz de fluoruro, si as se recomienda.

Firma de los Padres o Tutor ____________________________________ Fecha:____________________________________

Para uso de la oficina solamente

R Y G S V H

Chart #_________________

FLUORIDE VARNISH PROGRAM
This preventive dental program is available through the Health Department. A professional will apply a protective coating called fluoride varnish to your child's teeth as a preventive measure against tooth decay. To receive this service you must provide consent. We will bill Medicaid/Peachcare for this service or if you do not have Medicaid/Peachcare there will be a $5.00 charge.
NAME OF CHILD:___________________________________ DATE OF BIRTH:___________________________________ Male _____ Female ______ Race ________ Hispanic? Yes ___ No ____ Do you have Medicaid or Peachcare? _ _______
Health History
1. Has your child visited a dentist in the last 6 months? ________________ 2. Has your child ever had serious health problems? If so please explain.

3. Does your child have any allergies? If so please explain.
______________________________________________________________
PARENT SIGNATURE: _________________________________
DATE: ______________________________________________
****This service does not replace a comprehensive evaluation. It is our recommendation that a dentist regularly examine your child.
FOR OFFICE USE ONLY
Comments___________________________________________________________ ____________________________________________________________________ Varnish placed on and by: _______________________________________________

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East Metro Health District Dental Prevention Program
Your child's school is cooperating with the East Metro Health District (Health Department) to provide your child with the opportunity to participate in the Dental Fluoride Varnish Program. Fluoride varnish is a thin coating of resin that is applied to the tooth surface to protect it from decay. Fluoride varnish can retard, arrest, and reverse the process of cavity formation. Children with developmental disabilities are considered to have a moderate or high risk of developing cavities.
The dental team from the Health Department will make a visit to the school and provide your child with a dental screening, a fluoride varnish application, and a report of the findings to be sent home to you. If follow-up is necessary, additional information will be attached to the report.
The most common dental problems that children experience are dental cavities and gum disease. Most of these problems are preventable. Early prompt treatment can eliminate pain and infection. THIS PROGRAM, HOWEVER, DOES NOT ELIMINATE THE NEED FOR PROPER HOME CARE AND REGULAR DENTAL EXAMINATIONS.

Please check if appropriate and complete the medical history on the back of this form. Please return it to your child's teacher as soon as possible:
___ I want my child to receive the fluoride varnish application.
___ I do not want my child to receive the fluoride varnish application.

Name of Child: _______________________________________________________________________________________

Last

First

M.

Birth date________________ Teacher:__________________________________________________________________

Signature of Parent/Guardian: ____________________________________________________________Date:____________
Pre-application instructions:
Please give your child something to eat and drink before coming to school to receive the fluoride application.
Please be advised that the child's teeth may become discolored temporarily as fluoride varnish may have an orange brown tinge.
Do not brush the varnish off the child's teeth until the following day. If you have any questions contact Dr. Robert H. Robinson at (678) 442-6902.

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