Expanding Access to Topical Fluoride Varnish

Project Year


City & State

Pittsburgh, Pennsylvania

Program Name

CATCH Resident


Oral/Dental Health

Program Description

According to the American Academy of Pediatrics (AAP), oral health is one of the most unmet health care needs in school-age children and adolescents (1). Since the Surgeon General Report on oral health in 2000, there has been minimal decline in untreated tooth decay among this population. According to the CDC, more than half of children ages 6-8 have a cavity in their primary teeth, and ~57% of adolescents ages 12-19 have dental cavities in their permanent teeth (2). The gap in oral health inequities among adolescents is widening(3,4) According to the CDC more than half of adolescents aged 12-19 years from low-income families are twice as likely to have cavities and untreated decay compared to children from higher-income households (2,5). The COVID-19 pandemic worsened these disparities(6). Barriers to dental access, coupled with behaviors within this age group, have led to the decline of oral health in adolescence as discussed above(3). Barriers to obtaining dental care within this population include limited motivation to seek preventive care, lack of transportation to appointments, competing work and school schedules, and lack of access to oral health care providers accepting Medicaid insurance.(4,7,9). Untreated caries in school-age youth has numerous detrimental health consequences: oral pain, inflammation, and risk of infection, which are associated with poorer nutrition and physical development, psychological stressors and difficulties in academic performance from missed school, and worsening of underlying chronic disease (10,7). Caries among this age group are preventable. Topical fluoride varnish (TFV) application is recognized as one of the most effective strategies for preventing dental caries and improvement of oral health in all children (8). In addition to prevention, TFV has the potential to remineralize existing caries and halt the progression from caries to cavities(2). Based on the strength of USPSTF evidence-based recommendations, the ADA (American Dental Association) now recommends TFV use in all children 18 years and younger of moderate risk for caries every 3-6 months (11). Given the lack of access to dental care, particularly in the Medicaid insured pediatric population, recommendations for TFV application in non-dental settings (ie medical settings) are now standard. However, the maximum age that Pennsylvania Medicaid and commercial insurers will reimburse fluoride varnish application in a medical setting is 5 and 6 years respectively (9), leaving the school-age population without this covered service outside of a dental office. Project Goal: The main goal of this project is to evaluate an implementation plan for application of TFV at well child visits in children and adolescents ages 6-18 years. Primary Setting: The project will take place in an academic community-based practice that serves a predominately Medicaid-insured population in Pittsburgh, PA. Proposed Intervention: To identify the most feasible implementation plan, the proposed intervention involves designing potential models for implementing practice based TFV for 6–18-year-olds, assessing their relative feasibility based on stakeholder feedback, and pilot testing the preferred model in 20 patients. Models will vary by who (staff, hygienist or parent/patient), when (at what point during the encounter) and where (office or home) the TFV can feasibly be applied. Legal and cost implications of each mode will additionally be assessed. Consideration of supervised parent- or self-application (in older teens) of TFV is the most novel of the model; this stems from other parent-performed medication administration or medical procedures, such as COVID-testing. Feasibility of each model will be measured by relevant stakeholder acceptability, preference, and experience. Anticipated Results: We anticipate that stakeholder input will identify at least one model of incorporating TFV application in a primary care visit for 6–18-year-olds that will be feasible to implement.

Project Goal

The main goal of this project is to examine the feasibility of an implementation model for applying topical fluoride varnish at well child visits in children and adolescents ages 6-18 years.

Project Objective 1

Identify a feasible TFV implementation plan by developing at least 3 potential implementation models based on literature review, advisory board input, key informant interviews and health plan leadership discussions. Select the best fit (preferred) model to pilot test using stakeholder survey data (25 parent/patient and 10 staff/provider questionnaires).

Project Objective 2

Pilot test the identified model in 20 age-appropriate patient encounters once planning is completed. Pilot planning will involve gathering resources, developing training materials (including the training videos), and ordering supplies. During the pilot phase, feasibility surveys will be administered to 20 participating parents/patients and 10 staff.

Project Objective 3

Analyze and disseminate findings. Discussion with the advisory board will help inform the interpretation of the findings and next steps planning. We will continue to support the community coalition with hopes of engaging in opportunities to scale office based TFV implementation.

AAP District

District III

Institutional Name

Children's Hospital of Pittsburgh

Contact 1

Dakota Peterson

Last Updated



American Academy of Pediatrics