Ambulatory Pediatric Fluoridation
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Publication Date
2025
Keywords
oregon, oaa 2025
Disciplines
Medical Education | Pediatrics
Abstract
Context: Dental health is an important part of pediatric wellness. Early childhood caries represents the most common childhood chronic health condition. As such, dental health screening and intervention are crucial in primary care. Oral health disparities exist among children from low-income families, low family education status and Black and Hispanic children. These inequities are evidenced in a higher prevalence of cavities, lower treatment rates, and less access to preventative dental care. Fluoride varnish is a simple yet highly effective method of preventing dental decay in children- reducing the incidence of cavities by 30-50%. Americal Academy of Pediatrics recommends applying fluoride every 3-6 months until age 5 for all children, and every 3 months for high-risk children. USPFTF gives this a “B” recommendation. Goal: At PMG Milwaukie, there were 28 opportunities to apply fluoride varnish in September 2024. Only 4 patients received this treatment (14%). The goal of this project is to increase fluoride varnish rates during well child checks (WCC) for children ages 1-5 to 50% by March 31, 2025. Methods: Topical fluoride treatments during routine WCC for children ages 1 until age 6 were initiated through a workflow including clinic providers, medical assistants, and clinic leadership. In this workflow, the lead medical assistant will chart scrub and place the note “fluoride” in office visit notes. The rooming medical assistant will place a fluoride kit and toothbrush in the room, which also acts as a visual cue for the provider. The provider will educate the family on the importance of pediatric fluoride varnish, apply the fluoride varnish during the visit, and complete the billing, documentation, and after care instructions. For this project, the CPT code, documentation dot phrase, and after care instruction dot phrase were made clearly visible at each provider desk. Results: The baseline rate of pediatric fluoride varnish application in the clinic was 14%. PDSA cycles included following an idealized workflow, described above, provider reminders at individual desks including fluoridation coding instructions and dot phrases, a recommitment to the basic workflow after a downturn in rate of fluoridation around the holidays, and finally the most effective intervention; targeted reminders to providers seeing high numbers of children ages 1-5 resulting in a final fluoridation rate of 61%. Discussion: This project highlighted some of the challenges of implementing a new workflow in a busy primary care clinic in addition to obstacles in recommending new treatments and interventions to families. Barriers to providing higher rates of fluoride varnish at WCCs included providers remembering to discuss these recommendations, adequate time to focus on counseling around the importance of pediatric dental fluoride, and parents declining the service. Chart scrubs of the visit notes where fluoride was discussed but not applied highlighted the latter obstacle, as many possible varnish opportunities documented parental refusal. We noticed that the greatest improvement in rates of applying fluoride varnish came with focusing varnish application reminders on those providers in the clinic seeing the highest volume of pediatric patients. This finding also reinforces the small N number of this intervention. The overall goal of meeting a pediatric fluoride varnish application rate of 50% was met. Possible next steps include both improving high pediatric volume providers implementation of these recommendations and working long-term to address familial fluoride varnish hesitancy.
Area of Special Interest
Women & Children
Specialty/Research Institute
Pediatrics
