Dental fluoride treatments are among the most effective and efficient techniques for hindering tooth decay in children. But despite their proven effectiveness, and despite the fact that such treatments are often covered by insurance, too few children are getting them.

Very few privately insured young children receive recommended dental fluoride treatments at health wellness visits, according to a study published in the Journal of the American Medical Association (JAMA) Network Open. The study’s analysis of more than 328,000 well-child visits for privately insured 2- to 5-year-olds found that fluoride treatment was done in fewer than 5% of visits between 2016 and 2018.

Parental refusal and clinical intervention strategies

One common reason that children aren’t getting fluoride treatments is parental refusal. In a survey, nearly 80% of dentists said they believed fluoride refusal was a problem. In one study, refusal of fluoride was found to be correlated with refusal of vaccines, and as many as 51.5% of parents refused topical fluoride treatments.

“Tooth decay is the number one disease of early childhood, and fluoride plays a critical role in strengthening the enamel and preventing cavities,” said Dr. Jessica Buehler, Director of Dental Affairs at Delta Dental. “Unfortunately, in today’s world of information overload and patients getting their news through social media, there are many families that oppose or do not understand the value and importance of fluoride.” 

Reasons for parental refusal

Parental attitudes and beliefs about health are important determinants of fluoride refusal. Most common is the belief that fluoride is unsafe. Such concerns are often spread and amplified through social networks, the media and the internet. Other factors may include religious beliefs, a desire for autonomy and concerns about the true intent of fluoride treatments.

Clinical interventions

The following clinical strategies can help you improve communication with parents about topical fluoride treatments:

  • Assess parents’ knowledge, beliefs and attitudes early. Screen for possible fluoride hesitancy at the start of preventive visits by asking open-ended, non-judgmental questions, such as “Do you have any questions for me about fluoride?” This can help you assess beliefs and start a conversation.
  • Ensure your team is prepared. Make sure your staff of dental assistants and hygienists understands how fluoride works and why it’s important, as they will likely be the ones applying fluoride treatments. Acknowledge that parental refusal can be a problem and assure your staff that you are there to support them. “Auxiliary staff should not engage in an argument when a parent refuses fluoride,” suggested Dr. Buehler. “They should inform the dentist so that she or he can answer any questions the family may have.”
  • Obtain information about why parents are refusing fluoride. Avoid a pro-fluoride “sales pitch.” Instead, ask questions about what’s motivating a parent’s decision to opt out. Listening is key and can help build trust. Reassure the parent that you respect their health care decisions. Some parents may reconsider their decision after several discussions over time. Document conversations with parents so that future discussions can be framed appropriately.
  • Incorporate specific caries risk factors into discussions. Provide parents with an explanation of why fluoride is important based on the unique risk factors associated with each child. For instance, white spot lesions on the child’s teeth should be pointed out to the parent, with a description on how fluoride helps to prevent white spots from turning into cavities that require fillings.
  • Discuss alternative fluoride sources and behavioral strategies. Parents who refuse fluoride during dental and medical visits may be open to use of at-home fluoride products. Discuss alternative sources of fluoride that could be used at home, like fluoridated toothpastes and fluoride mouthwashes. Remind parents about the benefits and safety of fluoride in water. For parents who refuse all fluoride-containing products and water, emphasize that reducing dietary sugars and acids becomes even more critical in managing caries risk.

Fluoride treatments, your pediatric patients and you

Fluoride varnish is recommended by the U.S. Preventive Task Force and the American Academy of Pediatrics for all infants and children starting at tooth eruption through age five years. All children in this age category should receive fluoride varnish application at least once every six months, according to the recommendation. Most private insurers cover the procedure, and coverage with no cost-share for families is mandatory under the Affordable Care Act.

Most Delta Dental PPO™ and DeltaCare® USA plans cover fluoride treatments for children up to age 12, and many cover such treatments up to age 18, and for adults, as well. The specific codes for fluoride treatments are:

  • D1206 Topical application of fluoride varnish
  • D1208 Topical application of fluoride excluding varnish

Preventive dental care is important at any age, and we encourage you to give regular fluoride treatments to your pediatric patients. Developing a clinical workflow that includes fluoride application can greatly improve the oral health of children within your practice.