Team effort: Primary care doctors can decrease dental caries with fluoride treatment




Dental caries is the most common infectious disease of childhood especially in young children age two to five. For years, nondental primary care clinicians, particularly family physicians and pediatricians, have been asked to help address this issue in two major ways: counseling on appropriate preventive techniques and prescribing fluoride supplements in children who do not have adequate access to water fluoridation. Despite these steps, the incidence of caries in children has risen, especially in the last 20 years.

In Kentucky, we are particularly hard hit with dental disease, especially in our children. Nikki Stone, DMD, dental director for the UK North Fork Valley Community Health Center in Hazard, Ky. has spent the last 10 years traveling to schools in the four county region around Hazard (Letcher, Knott, Perry, and Leslie). Her initial findings were disheartening.



“Nearly 5,000 children were seen that first school year (2005), and the baseline data was disturbing, especially when compared to national data and the HealthyPeople 2010 goals. A staggering 58 percent of Head Start children and almost 70 percent of elementary school children had untreated tooth decay, and nearly 20 percent had urgent dental needs (pain/infection/rampant decay). At nearly every Head Start center visited over the four-county area, at least one child in each center had all 20 baby teeth grossly decayed with multiple abscessed teeth. Compared to national data, the children in this service area turned out to have the second highest untreated tooth decay rates in the nation, second only to the isolated Alaskan Native/Native American populations,” Stone said.

Oral Health and Test Scores

In addition, Stone’s work revealed several interesting findings. Schools she visited that had the lowest rate of untreated decay were also the schools with the highest test scores. Children can learn and perform better if they are not dealing with dental pain and disease.  Stone also found, not surprisingly, that Medicaid utilization rates for dental visits remains alarmingly low. This means that even though Medicaid covers dental care, and has done so for years, many children still do not access care.

In 2011, across Kentucky there were 113,000 children age zero-to-four enrolled in Medicaid. Of those, 65,000, or 57 percent, received dental services. In 2012, despite an increase in enrollees in this age group to 147,000, only 57,000, or 39 percent accessed dental services.  All age groups show a decline in utilization up to age 70, though the zero-to-four age group is the most dramatic. These children, as evidenced by Stone’s findings, are especially vulnerable to lack of dental care.

A Bright Spot

But there is a bright spot. Stone has shown with regular monitoring, appropriate use of fluoride varnish and dental sealants, and a tight collaboration with pediatric dental specialists, she can make a difference in these children’s lives. Stone’s program reports a decrease in the incidence of untreated dental decay in elementary age kids from 60 percent to 53 percent in the last six years.

Likewise, for Head Start children, there has been a decrease from 58 percent to 42 percent in untreated decay over the past six years. She partners with a pediatric dentist who travels an hour to Hazard once a week to see children with urgent needs, rather than making the children and their family travel that distance. This means that she has seen an increase in completed care (all decayed teeth treated appropriately), from eight percent to 64 percent by removing this additional barrier.

Primary Care Can Help

In the fall 2009 edition of the KAFP journal, Stone and I wrote about and encouraged the use of fluoride varnish by primary care clinicians, and stated, “Because many children do not see a dentist, it is up to clinicians in a child’s medical home to initiate counseling about good oral health habits as well as providing treatments, such as fluoride varnish, that can reduce early childhood caries.”

Providing fluoride varnish to the primary teeth of children from the time of tooth eruption until age five can reduce the risk of early childhood caries. More importantly, this procedure can be performed in a primary care clinician’s office with essentially no risk to the child and minimal cost in time and supplies to the clinician. In May 2014, the US Preventive Services Task Force gave a B recommendation for fluoride varnish application twice a year to all children by medical primary care providers.

Stevens Wrightson, MD is the medical director at the Bluegrass Community Health Center. Article adapted from the Kentucky Association of Family Physicians Journal Summer 2014, Volume 81.


Smiles for Life in Kentucky

As a part of Kentucky’s Oral Health Literacy campaign, the Kentucky Oral Health Coalition (KOHC) and other stakeholders seek to bring oral health literacy to all of Kentucky’s health professionals in the next two years. They have been partnering with pediatricians, nurses, family physicians, primary care centers, ob/gyns and others to offer a free online CEU on oral health.

The coalition has also partnered with Smiles for Life national steering committee members, managed care organizations, continuing education portals and universities to develop and implement an outreach strategy to increase the number of health professionals who complete the Smiles for Life online curriculum. We will promote and distribute an inter-professional continuing education unit created by Smiles for Life on oral health literacy. Additionally, medical students will be encouraged to incorporate oral health literacy as they begin their practice. The goal is to re-frame the partnership between dental professionals and other health professionals by treating the patient as a whole being.

The Smiles for Life curriculum was developed in 2005 by the Society of Teachers of Family Medicine. The original goal of the program was to provide educational resources to improve the oral health knowledge of physicians training in family medicine residency programs. The program has been revised several times to include additional components such as fluoride varnish, oral health during pregnancy, oral examinations and geriatric oral health. The Smiles for Life curriculum is the most comprehensive and widely used oral health curriculum available online to health professionals.

Since the site’s launch in 2010, almost 200,000 health professionals visited the site.  Last year alone, almost 24,000 online courses were completed for continuing education credit from all across the country. KOHC will work with the national site administrators to measure the state’s utilization rates of the Smiles for Life Curriculum by Kentucky health professionals.

If you are interested in helping with this effort, please contact Mahak Kalra at the Kentucky Oral Health Coalition at





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