1. How to Apply Fluoride Varnish
A Collaborative Effort between
Indian Health Service (IHS) and
the IHS Head Start Program
Welcome to “How to Apply Fluoride Varnish.”
This course is a collaboration between the Indian Health Service Head Start Program and the Indian Health Service Division of Oral Health and Medical Programs.

2. Course Objectives Describe Early Childhood Caries (ECC)
List two ways to prevent ECC.
Recognize the various stages of ECC.
Discuss the benefits of topical fluoride.
List the 5 steps to applying fluoride varnish.
Demonstrate the appropriate application of fluoride varnish.
List one key message for families to prevent ECC.
This course will provide an overview of Early Childhood Caries, or ECC, and describe its impact among American Indian and Alaska Native children. You will learn how to provide an oral health risk assessment, how to apply fluoride varnish, and key messages for families to prevent ECC.

3. Why are Baby Teeth Important?
Eating and nutrition
Holding space for the permanent teeth
Talking
Smiling
Sometimes I hear people say that baby teeth aren’t all that important. But baby teeth are critical to the health and well-being of every child. Baby teeth enable children to eat healthy foods. Baby teeth hold just the right amount of space for the permanent teeth. And of course, baby teeth are important for speech development and smiling.
I’d say baby teeth are very important!

4. What is Early Childhood Caries?
ECC is the presence of any decayed, filled, or extracted (due to decay) teeth in the primary dentition (baby teeth).
Involves infectious bacteria, often passed from mothers to babies.
The teeth often decay very quickly.
Unfortunately, I see something called early childhood caries, known as ECC, in many children. ECC is any tooth decay in a child under six years of age.
Dental caries is a transmissible disease involving mutans streptococci, lactobacilli, and other cavity-causing bacteria.
A more severe form of ECC occurs when the baby teeth decay rapidly, usually beginning with the upper front teeth and progressing to the back teeth as they erupt.

5. Effects of ECC Pain Infection Higher risk of new cavities
Missed school days and
difficulty concentrating in school
Effects of ECC include:
•Pain
•Infection,
•A higher risk of new cavities in both primary and permanent teeth
•Missed school days
•Inability to concentrate in school.  
Pain can also affect a child’s sleep and nutrition, again resulting in poor overall health and well being.  

6. What Causes ECC? Pathological Factors Protective Factors
Bacterial biofilm
Ingestion of simple carbohydrates
Reduced salivary function
TOOTH DECAY
Protective Factors
Fluoride
Antibacterials
Oral hygiene habits
Flow and composition of saliva
Structure of tooth minerals in each individual
Dental Sealants
NO TOOTH DECAY
Dental caries is a transmissible microbial infection that affects the tooth minerals. There are many factors involved in the initiation and progression of dental caries. The prevention of dental caries should take into account all contributing factors.
Pathological Factors
- Bacterial biofilm.
- Frequency of simple carbohydrates in the diet.
- Reduced salivary function.
Protective Factors
- Fluoride.
- Antibacterials.
- Oral hygiene habits.
- Flow and composition of saliva.
- Structure of tooth minerals in each individual.
- Dental Sealants.
The most important thing to remember is we want to tip the scale with less pathological factors and more protective factors.

7. Demineralization and Remineralization
Teeth demineralize or break down, and remineralize or rebuild, on a daily basis. This is happening constantly in our mouths. The early stage of demineralization which can lead to decay can be seen as a white spot lesion.
Even at this stage, the decay process is still reversible with topical fluoride.

8. ECC and AI/AN Children
76% of AI/AN children ages 2-5 have experienced dental cavities.
68% have untreated decay.
Over 50% have severe ECC.
1999 IHS Oral Health Survey
A 1999 IHS Oral Health Survey reported a staggering 76% of American Indian/Alaska Native children between the ages of two to five have experienced dental caries, 68% have untreated decay, and over 50% have severe Early Childhood Caries.
In the survey, we found that many American Indian and Alaska Native children experience dental caries before the age of two.

9. Two is Too Late!
The Indian Health Service adopted the slogan "Two is Too Late!" referring to the fact that by two years of age, many children already have cavities. Prevention efforts aimed at the baby teeth must be started with prenatal women and soon after the child's first tooth erupts at six to nine months of age.

10. Costs of ECC
Traditional dental treatment is largely ineffective at reducing the bacteria that cause ECC.
ECC can cost thousands of dollars to treat each child, even exceeding $8,000 when a child is hospitalized and treated under general anesthesia.
Traditional dental treatment of ECC is expensive and largely ineffective at reducing the bacteria that cause the disease.
Costs per child can range from $2,000 to $5,000 and even exceed $8,000 if the child is hospitalized and treated under general anesthesia. ECC places a huge financial burden on IHS, Tribes, third-party payers, Medicaid, and parents least able to afford treatment.
We don’t like for a child’s first visit to the dentist to be difficult on the child and family. If everyone knew what causes ECC and how to prevent it, we could improve the health of American Indian and Alaska Native children.

11. Medical and Public Health Programs
IHS DOH ECC Initiative
Dental Programs
CHR s
Head Start
Tribal Organizations
WIC
Medical and Public Health Programs
Indian Health Service, Division of Oral Health, has an ECC Initiative that is both comprehensive and collaborative.
Part of the ECC Initiative is the application of fluoride varnish by medical staff, Head Start staff, Community Health Representatives, public health nurses, and WIC staff.
Let me tell you about the benefits of fluoride and its effect on oral health.

12. Fluoride Inhibits demineralization Enhances remineralization
Inhibits plaque bacteria
Fluoride is a protective factor and key in the prevention and reduction of tooth decay. Fluoride works by inhibiting demineralization, enhancing remineralization, and inhibiting plaque bacteria.
In other words, fluoride works in many different ways to prevent cavities!

13. Ways to Obtain Fluoride: Systemic
Water
Prescription drops or tablets
Systemic, or swallowed, fluoride can even make teeth stronger as they develop. Sources of systemic fluoride include:
•Water fluoridation
•Prescription drops
•Prescription tablets
Indian Health Service does not routinely prescribe systemic supplements due to the poor compliance with this long-term course of therapy.
We recommend that everyone support community water fluoridation at every opportunity. The Centers for Disease Control identified water fluoridation as one of the 10 greatest public health achievements of the 20th century.

14. Ways to Obtain Fluoride: Topical
Fluoride Toothpaste
Fluoride Varnish
Fluoride Mouthrinses
Topical fluoride sources include fluoride toothpaste, topical fluoride treatments like fluoride varnish, and fluoride mouthrinses.
Unfortunately, fluoride mouthrinse is not recommended for children under six years of age, so from birth to five years of age, fluoride toothpaste and varnish are important tools to prevent ECC.

15. Fluoride Toothpaste
Recommend cleaning the teeth daily with a small smear of fluoride toothpaste as soon as the first tooth erupts.
At three years of age, brush daily with a pea-size dab of fluoride toothpaste
We recommend that parents start brushing their babies’ teeth twice each day with a small smear of fluoride toothpaste as soon as the first tooth erupts.
At three years of age, children’s teeth should be brushed twice daily with a pea-size dab of fluoride toothpaste.
Topical Fluoride Recommendations for High-Risk Children. Development of Decision Support Matrix: Recommendations from MCHB Expert Panel, 2008

16. What is Fluoride Varnish?
Highly concentrated topical fluoride treatment
Can reverse white spot lesions.
Safe for young children
Easy to apply
Fluoride varnish is a professionally applied, highly concentrated – 22,600 parts per million – fluoride product.
Various studies, including the Cochrane Review, have demonstrated fluoride varnish to be effective in preventing dental caries. In addition to the general preventive benefits, fluoride varnish can also reverse early white spot lesions that are the first sign of dental caries.

17. Advantages of Fluoride Varnish
Safe
Easy to Apply
Accepted by patients
No special requirements
Advantages of fluoride varnish are that it is safe for young children, easy to apply, is generally acceptable to patients, and does not require special preparation of the teeth or expensive equipment.

18. Research with AIAN children
Medical staff applied during well-child visits.
Children who received four or more application of varnish between the ages of 9-24 months of age had 35% reduced decayed surfaces over children who received none.
Holve S, IHS Primary Care Provider, Oct 2006.
Research by Dr. Steve Holve, an IHS pediatrician in Tuba City, Arizona, involved application of fluoride varnish by the medical staff during well-child visits. The children were followed over a three-year period until they were in Head Start.
Children who received four or more applications of varnish between the ages of nine and twenty four months of age had 35% fewer decayed surfaces than children who received no fluoride varnish.
Unfortunately, there was little benefit to receiving only three treatments, and almost no benefit to receiving one to two treatments.

19. Due to the high prevalence of dental caries, most AI/AN children can be considered high-risk for dental caries unless a dental professional has classified them differently .
Because American Indian and Alaska Native children have such a high documented prevalence of dental caries, they can be classified as high risk, at least until a dental professional determines that their individual risk is low or moderate.
When applying fluoride varnish on infants in public health settings, and children in Head Start classrooms, it is wise and cost-effective to consider all of the children at high risk for dental caries.

20. Who does What in AI/AN Communities?
Age Staff Protocol
9-24 months Medical Staff treatments
2-3 years CHRs, WIC, PHNs 3-4 treatments
3-5 years Head Start staff treatments per year
At Head Start, we're recommending that directors, teachers, health coordinators, or whoever dispenses medications be trained to apply fluoride varnish.
Fluoride varnish should be applied three to four times a year for all American Indian and Alaska Native children.

21. Work together to prevent ECC!
Fluoride varnish for every
infant and child
Dental screenings
Parent education
Caries Stabilization
I urge you to work with your medical, dental, and community partners to design a program to provide fluoride varnish to every infant and child in your community.
This should be combined with dental screenings, parent education, and caries stabilization using sealants, and fluoride-releasing glass ionomer restorations, called Interim Therapeutic Restorations (ITR).

22. 5 Steps to Applying Fluoride Varnish
Applying fluoride varnish takes 5 Steps:
1. Get ready
2. Provide an oral health assessment
3. Dry the teeth
4. Apply fluoride varnish
5. Provide the family with take home messages

23. Step 1: Getting Ready Supplies Fluoride Varnish Gauze squares
Non-latex gloves
Child-size toothbrush (optional)
Let’s go through the five step process together. The first step in applying fluoride varnish is to get ready. You will need unit dose of a fluoride varnish product, gauze squares, and non-latex gloves.
The varnish comes in a packet with a disposable applicator. A child-size toothbrush is optional but it works well to show caregivers how to brush their child’s teeth. It can also serve as a mouth prop to keep the mouth open while you provide the oral health assessment. Make sure you have hand sanitizer and a wastebasket nearby.   
If you are setting up to work with a group of children, Head Start for example, you will also want to use paper towels to lay under the setups. You can even assemble and stack the setups ahead of time.

24. Principles of Infection Control
Take action to stay healthy: wash hands or use an alcohol-based hand rub before and after applying varnish on each child.
Avoid contact with blood and body fluids: wear gloves.
Make items safe for use: use all disposable items.
Limit contamination: set up on a paper towel and dispose of all items after each application.
Part of getting ready is following the four principles of infection control recommended by the U.S. Centers for Disease Control:
Take action to stay healthy. This involves washing your hands, or using an alcohol-based hand rub, before and after applying fluoride varnish on each child. Also, do not work on children if you are sick.
Avoid contact with blood and body fluids. When we apply fluoride varnish to children’s teeth, we use 2x2 gauze and a varnish applicator. Because neither an air-water syringe nor a dental handpiece is used, we are not at risk of exposure to aerosols or spatter. We do not have to wear masks or protective eyewear and clothing. However, our hands could be at risk of exposure. That is why gloves are worn when applying fluoride varnish. If you have long hair, it is also a good idea to tie it back, out of your face.
Make items safe for use. Because only disposable items are used when applying fluoride varnish, there is no need to learn sterilization procedures. Disposable items are intended for use only on one person. They are not intended to be cleaned, disinfected or sterilized and used on another person. Gloves are single-use items. This means we do not wash gloves and reuse them.
Limit contamination. We limit contamination when we set-up materials for fluoride varnish on a paper towel. The paper acts like a barrier covering the work surface, and limiting contamination. It also makes clean-up easier. All the single-use disposable items (including gloves) can be wrapped in the paper towel, and disposed of in a trash container.

25. Applying Infection Control Principles
Set Up Application Clean Up
Now let’s talk about how to use these principles of infection control when setting up, applying fluoride varnish, and cleaning up.
Set-Up
Make sure hands are cleaned before placing a paper towel on the work surface. Place the 2x2 gauze, fluoride varnish and applicator, and a pair of gloves on the paper towel. A child-size toothbrush is optional.
Fluoride Varnish Application
Wash hands and put on gloves before applying the fluoride varnish.
Clean-Up
Give the toothbrush to the child to take home.
Wrap used materials including gloves in the paper towels and throw them away. You will want to have a wastebasket nearby.
Wash hands or use a hand sanitizer, and set-up for next child.

26. Step 2: Oral Health Assessment
Use the knee to knee position if you are working with babies and very young children.
Children 3 and older can stand in front of you.
Now you’re ready to position the child and provide an oral health assessment.
Note the knee-to-knee position. The child is initially held in the mother’s arms and slowly lowered to the health professional’s lap. Ask the parent, or another helper, to hold the child’s hands and help keep the child from wiggling. This can also be done in daycare centers using teachers or other volunteers as helpers.
For children three and older, the child can stand in front of you.

27. If you use a toothbrush…
Show the caregivers how to brush
Use the toothbrush as a mouth prop
If you are a medical or community health provider seeing babies and toddlers, you might want to have a child size toothbrush handy. You can show caregivers how to brush their children’s teeth and then you can use the toothbrush as a mouth prop while you provide the oral health assessment. This will keep the child from biting down on your fingers….ouch! !

28. Oral Health Assessment
We’re not asking Community Health and Head Start staff to do an oral screening, but when you are applying fluoride varnish, you might see some disease that will trigger a referral to the dentist. Therefore, we want you to have some understanding of what ECC looks like and when a child needs to be referred immediately to a dentist.

29. First Sign of ECC: White Spot Lesions
Can be remineralized with
Changes in diet
Fluoride varnish
Daily brushing with
fluoride toothpaste.
The first sign of ECC is white spot lesions.
These are demineralized chalky white areas, often around the gumline.
These white spot lesions can be remineralized with changes in diet, fluoride varnish and daily brushing with fluoride toothpaste.
If these lesions are not remineralized, they will progress to pitted brown areas.

30. Early and Moderate ECC
The early and moderate stages of ECC begin with brown pitted areas on the teeth.
If not treated early, cavities progress deeper into the tooth.

31. Caries Stabilization: ITR
Ask your dental clinic if they provide Caries Stabilization and ITR for young children.
Children with early and moderate ECC would benefit from ITR. ITR is a component of caries stabilization using fluoride releasing restorative materials that can actually help heal the lesions. These fillings can often be placed quickly and without the use of drills or local anesthesia.
Ask your local dental clinic if they provide ITR for young children.

32. Severe ECC
All too often I see ECC left untreated, allowing the teeth to continue to decay until there is little tooth structure left.
Notice how the upper teeth in these pictures are decayed, often right to the gumline while the lower teeth rarely decay at all. This is due to the powerful buffering action of the saliva that pools in this area of the mouth.
These children all need to be referred to the dental clinic for treatment.
If you are in a Head Start or other community-based setting, you can still apply fluoride varnish for these children, even on the teeth with cavities. It may not make a big difference, but it won’t hurt anything and might provide protection for the teeth that don’t yet have cavities.

33. Step 3: Dry the teeth Use the gauze squares
In this step, use the gauze squares to quickly dry the teeth and remove any heavy plaque

34. Step 4: Apply Fluoride Varnish
Using the applicator that comes in the package, apply varnish to all of the surfaces of the teeth. Begin with the upper teeth. Apply varnish to the outsides of all of the teeth and then the insides.
Repeat this procedure with the lower teeth.
The important thing is to develop a pattern for applying the varnish that works for you.

35. Fluoride Varnish Video
(You can either show the youtube video at this point or refer participants to the video so that they can watch it later on their own.)
Before watching the video
Take a few minutes to watch a short video on the knee-to-knee technique for fluoride varnish application. The video includes a method where all of the teeth are not varnished. Please disregard this information and make sure you apply fluoride varnish to ALL of the surfaces of ALL of the teeth.

36. Step 5: Take Home Messages
Don’t brush until the next day for optimal benefit of the fluoride varnish.
Brush daily with a fluoride toothpaste.
The final, and very important step in the process, is the take home message.
Let parents know that their child’s teeth may be slightly discolored until they are brushed. Tell the parents not to brush their child’s teeth for 24 hours. These products change rapidly, so when in doubt, follow the directions and recommendations on the package.
Most important of all, remind caregivers to brush their children’s teeth twice daily with fluoride toothpaste!

37. All of the supplies are disposable and intended for single use only!
5 Steps Review
Let’s review the five Steps for applying fluoride varnish.
Step 1. Getting ready
Supplies:
gauze squares
fluoride varnish
non-latex gloves
toothbrush (optional)
If you are setting up to work on a group of children, you will want to use paper towels to lay under the setups. You can even assemble and stack the setups ahead of time. You will also want to have hand sanitizer and a wastebasket nearby.)
 Step 2. Provide an oral health assessment
Position the child in the knee-to-knee position if you are working with babies and very young children.
 Have the child stand in front of you if you are working with a group of Head Start children.
Look for chalky white or brown spots. Make a referral to the dental program if the child has obvious cavities.
Step 3. Dry the teeth
Use the gauze squares to quickly dry the teeth and remove any heavy plaque.
Step 4. Apply fluoride varnish
Use the applicator to apply varnish to all tooth surfaces.
Step 5. Provide the family with take home messages
Instruct the parents according to the manufacturer’s directions on the package.
 Reinforce the importance of twice daily brushing with fluoride toothpaste.
Note: During all steps, be sure to follow the principles of infection control.
All of the supplies are disposable and intended for single use only!

38. What can YOU do to prevent ECC?
Provide oral health screenings and fluoride varnish for the children you work with.
Provide oral health messages to families in your community.
To prevent ECC, children need to be seen for preventive care starting when the first tooth erupts and continuing at least until the child is five years old.
YOU can help by providing oral health screenings and fluoride varnish treatments for the children you work with.
You can also help by educating families about prevention and encouraging them to brush their children’s teeth twice daily with fluoride toothpaste beginning when the first tooth erupts.

39. Together we can make a difference!

40. Summary
This course provided an overview of Early Childhood Caries, and described its impact among American Indian and Alaska Native children. You learned how to provide an oral health risk assessment, how to apply fluoride varnish, and how to present key messages for families to prevent ECC.

41. Instructions for Course Completion
After completing the course and receiving a score of at least 80% on the posttest, you will receive a certificate.
After demonstrating application of fluoride varnish on a child in the appropriate age group, have a medical or dental health professional sign your certificate.
Standing orders must be provided by a dentist or physician. Make sure he/she is licensed in the state you work in if you will be providing fluoride varnish treatments for non-native children.
After completing this course you must take the posttest and score at least 80%. You will then receive a course completion certificate, a handout of the 5 Steps, and a standing orders form. If your local dental or medical clinic uses a different form for standing orders, use their form.

42. Here is a copy of a completed certificate.
You’ll be getting one too if you pass the posttest with a score of 80% or greater!
(Administer posttest. After completion, collect and score them. Everyone who gets a score of 80% or higher can receive a certificate completed with his/her name and date. The doctor/dentist name and date will be completed later after they demonstrate application of fluoride varnish.)
Handouts
Posttest
Certificate
5 Steps
Standing Orders

43. Special Thanks
We want to thank California First Smiles for use of some of their photos and Dr. Joanna Douglass for use of her video.
Now, let’s take the posttest!