AAP Adds Fluoride Varnish to Anticipatory Guidance Schedule

Laird Harrison

August 31, 2015

Pediatricians should make sure children's teeth are getting varnished with fluoride, the American Academy of Pediatrics (AAP) recommends.

The academy added the recommendation to the 2015 version of its Recommendations for Preventive Pediatric Health Care, which it published online August 31 and in the September issue of Pediatrics.

"Once teeth are present, fluoride varnish may be applied to all children every 3 to 6 months in the primary care or dental office," write the authors, who were from the AAP's Committee on Practice and Ambulatory Medicine and the Bright Futures Periodicity Schedule Workgroup.

The fluoride varnish recommendation is the only change the committee made this year to their checklist of care children should receive at routinely scheduled visits with pediatricians.

The varnish recommendation is not new. The AAP first endorsed the guidelines on fluoride use from the Centers for Disease Control and Prevention in 2001. It provided reasoning for the recommendation in a 2014 clinical report published in Pediatrics.

Fluoride has both risks and benefits for children, and pediatricians must be aware of these to promote their patients' oral health, write Melinda B. Clark, MD, and Rebecca L. Slayton, DDS, PhD, the authors of the 2014 report.

Although largely preventable, dental caries remains the most common chronic childhood disease in the United States. In this condition, acid produced by bacteria erodes the enamel of the teeth, creating cavities. Fifty-nine percent of 12- to 19-year-olds have at least one cavity, according to the 2014 report.

Caries can progress to local infections, occasionally causing serious illness or even death. It causes children to miss hours of school and caregivers to miss hours of work, and it increases the risk for systemic illnesses such as diabetes.

Early childhood caries is the single greatest risk factor for caries in the permanent dentition.

Although the oral health of Americans has been improving in general, dental caries among children aged 2 to 4 years increased between the 1988-1994 and 1999-2004 National Health and Nutrition Examination Surveys, Dr Clark and Dr Slayton write.

Research long ago established the effectiveness of fluoride in stopping the progression of the disease. It promotes enamel remineralization, reduces enamel demineralization, and inhibits bacterial metabolism and acid production, they add.

The only proven adverse reaction is fluorosis, or subsurface hypomineralization and porosity between the developing enamel rods, they note. Typically, fluorosis causes striations or opaque areas that are not readily visible in mild cases. Moderate and severe forms of fluorosis can cause pitting and brittle incisal edges, but these are rare in the United States.

Fluoride varnish is a concentrated topical fluoride that both dental and nondental health professionals can brush onto their patients' teeth. It sets on contact with saliva. It is well tolerated by infants and young children and has a prolonged therapeutic effect.

The concentration of fluoride varnish is 22,600 ppm (2.26%), and the active ingredient is sodium fluoride.

Research on fluoride varnish has led to recent endorsements. In May 2014, the US Preventive Services Task Force gave the evidence for the efficacy of fluoride varnish a "B" grade, meaning "There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial."

Because many children do not receive dental care at young ages, pediatricians have a unique opportunity to help their patients avoid caries by applying this varnish, Dr Clark and Dr Slayton conclude.

Pediatrics. Published online August 31, 2015.

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